Follow-up on corrections·December 5, 2023

Licensing Program Analyst (LPA) Olson conducted an unannounced case management visit to issue deficiencies observed while investigating complaint #29-AS-20230531110058. LPA met with Staff and Administrator over the phone and informed them the reason for the visit. During the investigation on 6/8/23 LPA Chavez went to the facility for the unannounced initial visit and was greeted by Staff 1 (S1) and Resident 2 (R2). LPA Chavez observed S1 tell R2 to “get back and go away.” LPA interviewed R2 at 1:31pm who stated they do not like S1 because they are mean to R2. At 1:45pm LPA observed Resident 3 (R3) stand up and R2 stated “do you want to see who she [LPA] is?” S1 went over to residents and R2 stated “ you won’t even let [R3] see who she is, you’re a mean lady. Do you know you’re a mean lady?”. S1 responded, yes I’m a mean lady.” Interview with Administrator and Licensee revealed that R1 had a psychotic breakdown and was admitted to a mental institution on 6/5/23. R1 was bolting out the door and staff tried to get R1 back in the house, and grabbed R1’s arm to get R1 back. Administrator stated that R1 told them Staff 2 (S2) was mean to R1. Administrator explained there was tension between them because R1 wanted their medication earlier then prescribed and S2 wouldn’t give them to R1. Additional interviews with residents revealed the main staff member S3 is a great caregiver and had no issues with the, but multiple residents stated Staff 4 (S4) is constantly rude to staff and residents. Based on the observation and interviews, residents were not treated with dignity by staff during verbal interactions and when they grabbed R1’s arm. Exit interview, deficiencies issued on 809-D, report given, appeal rights given.