Complaint Investigation Report

Allegation: Staff unable to meet client's needs.

The complainant’s concern was that the Licensee/Administrator unknowingly accepted a resident who had a violent behavior. To investigate this allegation LPAs requested R1’s facility records for Resident #1 (R1), which include but is not limited to a Pre-placement Appraisal, Appraisal Needs and Service Plan, Physicians Report, Admissions Agreement, ID Emergency Sheet, and training for staff, however the documents were not provided. Interview with the Administrator revealed that they had not done a complete preplacement assessment prior to accepting R1. The Administrator did not follow the facility’s plan of operation pre-admissions policy and procedures. In addition, the facility caregiver was not provided appropriate training based on R1’s needs. As a result of this the licensee was not familiar with the resident needs and historical behavior. On 02/16/2025, R1 refused prescribed medications and food. At some time during the day R1was not doing well and attempted to exit the facility through the living room sliding door and broke the glass door. The staff attempted to provide aid to R1, however R1 exhibited violent behavior towards staff and resident #2 (R2) in care. R2 was hit by R1, no injury noted according to the Administrator. Staff #1 (S1), present during the incident needed medical attention and drove himself to the hospital.

Moreover, LPAs conducted interviews with six (6) out of six (6) residents who informed LPAs that they are made to stay in their rooms and their care needs are not being met by the facility staff. Lastly, during the visit, LPAs observed that resident’s medication, meals, incontinent, and other needs were not taken care of. Based on the lack of documentation, interviews, and LPA’s observation this allegation is Substantiated.

Exit interview conducted copy this report signed and delivered.