Complaint Investigation Report

Staff did not ensure resident feels safe in the facility.

Based on interviews conducted, Resident 1 (R1) was moved from Assisted Living to Memory Care Unit (Compass Rose) due to Dementia diagnosis

Staff interviewed state R1 and R1’s husband who were living in the same apartment in the assisted living argued a lot due to R1’s behavior. Staff 3 (S3) state there was an incident when R1’s husband pushed R1 during an argument.

LPA obtained a copy of an undated letter from former Executive Director Candice Moses and Physician’s Report addressed to R1’s husband. The letter states that due to R1’s diagnosis of Dementia, R1 needed to be moved to the Memory Care because R1 needed specialized care in a safe environment. The letter also states. “I assure you that she is happy and content and is getting all the attention that she needs and deserves.”

LPA L. Fontanilla reviewed R1’s Service Plan dated 04/23/2020. Service Plan indicates, “Psycho/social – additional support at night. Resident requires additional support at night due to disturbed sleep or other needs. Support at night needed.”

A review of SOC 341 filed by formed Director state R1 was screaming for help. When staff responded, staff noted, “R1 was backed up to the wall on the bed and R1’s husband was standing over R1 screaming. R1’s husband took away R1’s pendant and did not allow R1 access to wheelchair.” Brentwood Police Department was notified.