complaint·March 19, 2024

LPA also attempted to conduct a telephone interview with R1's physician, but was unsuccessful. On 11/30/23, LPA Maldonado conducted a subsequent visit to the facility for the purpose of continuing the investigation. LPA conducted an interview with Staff# 6 (S6). The investigation revealed the following: Regarding allegation: Staff did not prevent a resident from biting another resident in care. It is alleged that on 10/30/23, at about 11:00PM, an incident occurred where R1 wandered into another resident's room and R1 had a bite mark on R1's arm, as R1 was not being monitored properly. Per staff interviews, (5) of (6) staff stated that R3 had pressed R3's pendant for assistance. Upon arrival, staff discovered R3 holding down R1. R1 had bitten R3 and R3 bit R1 back to try to get R1 off from R3. Staff were able to separate the residents and law enforcement was called to file a report. (6) of (6) staff stated they were aware that R1 was a wanderer and had attempted to enter other resident's rooms prior to this incident. However, R1 was redirected when observed attempting to enter other rooms and staff did not have concerns prior to the incident. Per R1's Physician's Report, dated 9/07/23, it was noted that R1 had a history of aggressive behaviors. Per resident interviews, R3 admitted to biting R1 due to R1 entering R3's room while R3 was sleeping and attempting to pull R3 off R3's bed. R3 stated staff took quick action and were able to remove R1 from R3's bedroom. Per incident report dated 10/30/23, the facility reported the incident of R1 biting R3 and R3 biting R1 in return. Regarding allegation: Staff did not provide adequate supervision to a resident in care. It is alleged that facility staff were not aware that R1 was often attempting to enter other resident's rooms and taking their personal possessions, and were not aware of R1's whereabouts. Per staff interviews, (6) of (6) staff stated they were aware that R1 was a wanderer and had attempted to enter other resident's rooms prior to this incident. However, R1 was easy to redirect when observed attempting to enter other rooms and staff were aware of resident's whereabouts as R1 was always walking the halls, where staff could see R1. (6) of (6) staff stated that no complaints from other residents, or suspicion, that R1 was taking others' personal possessions, was reported. (4) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Staff did not properly conduct a urine test for a resident in care. It is alleged that an LVN at the facility did not properly store or handle a urine sample obtained for R1, as the test results were found to be invalid upon testing, by R1's physician. LPA attempted several times to conduct an interview with R1's physician regarding the allegation, but was unsuccessful. Per staff interviews, (5) of (6) staff could not corroborate the allegation. S1 stated that a urine sample was collected for R1 and results were provided by the lab company. S1 could not recall the exact dates. Per R1's medical records, on 10/03/23, the facility received a physician's order to collect a urine sample. A "Final Report" from the lab company, dated 10/20/23, indicate that a urine sample was collected and received for R1 on 10/18/23 and results regarding the sample were provided to the facility on 10/20/23. (Report continued on LIC9099-C... (4) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Facility illegally evicted a resident in care. It is alleged that on 11/02/23, R1 was informed that R1 needed to leave the facility immediately, without any prior or proper notice. S1 stated that on 11/02/23, R1's responsible party took R1 to the hospital. S1 stated to have contacted R1's responsible party to inquire on R1's return date, which was the following day. S1 was notified shortly after by other facility staff that R1's responsible party had came to pick up R1's furniture and left without notice. Per S6, R1 did not give proper notice prior to moving out. S6 stated that R1's responsible party contacted S6 to inform S6 that R1 was living elsewhere and would not be returning to this facility. S6 denied evicting R1. (6) of (6) staff interviewed stated to not know the reason for R1 moving out of the facility. (4) of (6) residents interviewed could not corroborate the allegation. Regarding allegation: Staff did not ensure that resident was fed. It is alleged that staff were not making sure that R1 was eating R1's dinner for the first month that R1 resided at the facility. Per staff interviews, (6) of (6) staff denied the allegation and stated that they would report any issues/concerns of residents refusing meals or not eating. Per R1's Needs and Services Plan, R1 required notice of mealtimes. (6) of (6) staff stated that upon admission to the facility, it was noted that R1 was active and could not sit for a proper meal. However, staff ensured R1 was eating meals by providing more finger foods due to R1 always "on-the-move". Per S1, R1's physician was notified of this. Per R1's medical records, the facility received a physician's order dated 9/29/23, indicating "ok to do finger food". (4) of (6) residents could not corroborate the allegation. Regarding allegation: Staff did not ensure that resident's hygiene needs were being met. It is alleged that R1 was combative and facility staff were unable to bathe the resident for three weeks. Per Skin Integrity Monitoring forms, it was discovered that on 9/16/23, it was documented that R1 refused a skin integrity check, and on 10/10/23, it was documented that R1 refused a shower. Per R1's Physician's Report, it was noted that R1 required assistance with baths. Per staff interviews, (6) of (6) staff denied the allegation. Staff stated that R1 was combative, however they made all attempts to bathe resident as needed and ensured hygiene needs were met. (4) of (6) residents interviewed could not corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegations are Unsubstantiated. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Executive Director, Michele Johnson, and copy of this report was provided.