complaint·March 21, 2023

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with the Administrator and discussed the findings. This investigation included a thorough review of resident records and other documents; interviews with witnesses and staff; site visits to the facility. The following determinations are made: R1 and R2 were involved displayed aggressive behaviors with each other on many occasions while in care at the facility; Records show that the behaviors were addressed in the residents' care plans; Residents' care notes document reasonable steps taken by staff to deal with the aggressions; Most incidents were reported as required by 87211; Two incidents which were identified as not reported may not have rose to the level of requiring a report and sufficient information to make a determination of requirement to report was not found. Although the allegations may be true, or valid, based upon the documents reviewed and statements taken, there is not as preponderance of evidence to prove the allegations or, are not, true. Therefore, the allegations are UNSUBSTANTIATED. No citations issued today. Report left.