Complaint·December 15, 2024

Based on interviews conducted during the course of this investigation, it was learned that R1 was very aggressive and often prone to physical confrontations with facility staff, residents, or other third party members who were present at that time. It was learned that facility residents were constantly in fear of R1 and had to tiptoe around R1 so as not to trigger any aggressive responses from R1. It was learned that facility staff were also working their shifts in fear of R1 and were always on high alert since they were well aware of R1's explosive behaviors and outbursts. It was learned that R1's behaviors were easily triggered and facility staff and visiting family members were unaware of what these triggers were so they had to always proceed with caution around R1 so as to avoid any physical confrontations. It was learned that R1 was in need of a one to one care situation since R1's behaviors and cognitive issues needed to be addressed with more direct supervision and redirection. It was learned that this issue of more direct supervision was not addressed until later on after several incidents had already taken place. It was learned that R1 was involved in several incidents involving other facility residents, staff members, and other third party members. It was learned that on one incident R1 was verbally abusive and grabbed hold of another resident and attempted to throw them to the ground. Another incident involved R1 taking a swing at a facility staff person causing harm and inflicting collateral damage to another resident who was just nearby. It was learned that R1 had gotten agitated and heated when attempts were made to redirect R1 to where it was learned that R1 picked up a cup of coffee and threw it into the face of a third party member. In addition, the splash from the coffee being thrown also ended up on another resident who was merely nearby. Incidents such as grabbing a residents eyeglass wear and throwing it for no apparent reason was also learned during this investigation involving R1. It was learned that later on, after all of these incidents and reported events to this facility were made, R1 did finally receive a direct one on one caregiver and was eventually moved out of the second floor down to the first floor. It was learned that R1 was kept on the first floor for a majority of the day along with R1's one on one caregiver and was brought back up to the second floor where R1 was then allowed to enter R1's bedroom to sleep at night. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated representative at this time. Exit Interview