Complaint·December 16, 2024

On March 22, 2024, LPA Steve Chang interviewed ADM, James Dial. ADM stated on March 7, 2024, he spoke with R2’s authorized representative for 2 hours. LPA Chang interviewed Staff S1. S1 stated Staff S4 called R2’s authorized representative, but no one picked up the phone and could not leave a message. S1 stated he/she spoke with R2’s authorized representative on March 7, 2024, at 3:00pm. LPA Chang interviewed R2’s authorized representative. (AR). AR stated the facility notified him/her about the incident in question, the following day. On November 27, 2024, LPA Manuel Monter interviewed staff S4. S4 stated he/she had called R2’s authorized representative on March 6, 2024, but no one answered. S4 stated she left a voicemail. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 2 Out of 2. LPA Chang interviewed R1. R1 did not respond to LPA’s questions and was unable to provide answers to LPA’s questions. On November 21, 2024, LPA Monter interviewed staff S5-S10. S5 S6 S7 S8 S9 S10 stated R1 has the behavior of trying to enter other residents’ bedrooms. S5 & S8 stated since R1 moved into the facility, he/she has had the behavior of attempting to enter residents’ bedrooms. S5 - S10 stated staff are supposed to redirect R1 if he/she is trying to enter another resident’s bedroom. S5 stated staff are supposed to lock resident bedroom doors to prevent other residents from entering their bedrooms. On November 27, 2024, LPA Monter interview staff S2-S4. S2 – S4 stated R1 has the behavior of entering other residents’ bedrooms. S2 stated on March 5, 2024, he/she was in the activity area/hallway, filling out paperwork in the hallway with staff S3. S2 stated he/she was 5 feet away from R2’s bedroom. S2 stated he/she didn’t see R1 enter R2’s room. S3 stated he/she doesn’t remember what had happened on March 5, 2024. S3 stated “when we don’t have eyes on R1, that is when he/she enters others bedrooms.” S4 stated on March 5, 2024, he/she was in the med room doing his/her end of shift report. S4 stated a staff member had told him/her that he/she couldn’t find R1. S4 stated R1 was then found in R2’s bedroom. On December 5 and 13, 2024, LPA Manuel Monter interviewed staff S1 and S11. Both staff interviewed stated R1 had the behavior of entering other residents’ bedroom. S1 and S2 stated it was one of his/her behaviors, which he/she had since he/she moved in. S1 and S2 stated staff are supposed to redirect R1 when he/she is trying to enter another residents bedroom. A review of R1’s progress notes revealed multiple instances where R1 had entered or attempted to enter other residents’ bedrooms. From the day R1 had moved in, August 16, 2023, till March 6, 2024, R1 had 10 instances of entering another residents bedroom. Based on a review of R1’s Physicians Report, dated August 4, 2023, R1 has a neurocognitive disorder. R1 is also confused and has wandering behavior. Page 2 Out of 3. Based on a review of R1’s individualized Service plan, dated November 29, 2023, R1 has dementia. Under need, the form states R1 wanders into apartment agitating other residents. The form also states the task description for this behavior is to closely observe and guide wandering & to Cue or redirect for safety. Based on a review of a facility incident Report (IR), dated September 13, 2023, R1 was found in resident R3’s room. R3 stated R1 had punched him/her on the face. The IR stated that R3 did have an observable small cut on the inside of his/her upper lip. The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Holly Suiter - Executive Director/Administrator. A signed copy of this report was provided along with appeal rights. Page 3 Out of 3. END OF REPORT.