complaint·May 12, 2022

While the note states that R1's wife and doctor was notified, there was no reassessment of R1 to document these new behaviors. LPA Colvin observed a single Resident Assessment for R1 (dated 11/17/21), in which the only items noted under Behavior/Cognitive Support are: 1. "At risk if allowed access to personal grooming and hygiene items" 2. "Not able to exit building without verbal cue", 3. "Consistently disoriented to time and person", and 4. "Current social behaviors: Very Social". Additionally, LPA Colvin requested to see the staff notes for the last 30 days for R1. Upon review of these notes, LPA Colvin observed that the notes are medical/physical health related, and do not document R1's behaviors and staff's response to them. There is evidence of R1 having displayed behaviors (sexual behaviors & wandering in state of undress & into other resident rooms) other than those indicated on R1's last assessment, and these behaviors could cause harm to other residents. Since the facility has not completed a new reassessment of R1 and clearly identified how they are going to address these behaviors, and furthermore, have no documentation to show that these behaviors are being addressed, the complaint " Staff not ensuring a safe and healthful environment" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Wellness Director Shannon Wilkerson during the exit interview. *Note: When LPA Colvin was going over the findings of the complaint with Wellness Director Shannon Wilkerson, Shannon informed LPA Colvin that another Service Plan was done for R1 which addressed these behaviors, but that it was on the computer. Shannon returned after a period of time with the same Service Plan from R1's move into the facility, but this plan had an attached "Resident Care Associate Guide" dated 11/15/21. This page additionally had a hand-written note at the bottom, dated 12/10/21, which included directions for staff to redirect R1 for sexual behaviors and wandering. LPA Colvin observed that this note is not signed, and since it is hand-written, LPA Colvin cannot verify that it was done on that date and not today. Additionally, R1 did not have a reassessment to accompany this updated Service Plan. Shannon additionally provided LPA Colvin with proof of staff training on 12/9/21 & 12/15/21 for residents with sexual behaviors. This training did not include any mention of documenting residents' behaviors or staff's intervention.