complaint·October 9, 2024

On the allegations that " Staff did not prevent a resident from drinking another resident's drink and Staff did not prevent a resident from running naked while in care,” it is the reporting parties concern that Resident #2 (R2), took and drank Resident #1’s (R1) drink on two occasions, and on the night of 2/21 to 2/22, R2 was running through the facility naked until they could be guided to their room. Staff interviews revealed that R2 does exhibit certain behaviors, such as trying to drink other residents’ drinks and getting out of their room undressed, however all staff interviewed regarding these allegations revealed that they provide support by re-directing R2 and provide care and supervision. Staff stated that they try to intervene as soon as they notice certain behaviors, that the other residents are aware of R2’s behaviors, and they inform new residents as well. They try to prevent it but when R2 takes drinks from other residents, they provide the residents a new drink. Walking around without clothes is not something that is allowed, and if staff sees R2 without clothes they will re-direct them and R2 will go with the staff to get dressed. Staff stated that R2’s behaviors have been discussed by staff and the administrator to address them. Furthermore, assistant Executive Director revealed that R2 has a service coordinator from Tri-Counties Regional Center, and they are currently trying to work with them to get R2 a 1:1 to provide further support for R2. File review revealed that R2 experiences certain challenges, which include fixation on food and challenges with maintaining appropriate social boundaries, however these challenges have been addressed by staff, and R2's service coordinator. R2’s service care plan dated 04/04/2024, revealed that R2 went through medication changes/adjustments the previous quarter that show improvement in their behavior. On the allegations “Staff did not prevent a resident from drinking another resident's drink and Staff did not prevent a resident from running naked while in care.” Information obtained from interviews and file review revealed, R2 does present behavior challenges, however R2’s behaviors have been addressed by Staff and TCRC Service coordinator. Although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegations are deemed Unsubstantiated at this time. Exit interview conducted. Today's report was reviewed and provided to the Executive Director.