Complaint Investigation Report

The investigation revealed the following: Regarding Allegation #1 : Staff isolated residents for an unreasonable period. This complaint alleged facility staff isolated R1 for an unreasonable period. LPA Calderon conducted an interview with A1. A1 expressed that staff does not isolate residents inside their room. A1 expressed that resident room doors have no lock, and residents can come and go as they please. A1 expressed that residents have health issues and staff are trained to redirect resident actions (communication and mood training (dated 06/23/2023 and 02/17/2023) when needed and there is no reason to isolate any resident. A1 expressed that other than leaving the facility without staff residents can go into the back yard when they would like. LPA Calderon conducted an interview with S1-S2. S1 expressed that at no time has any staff member locked R1 or any other resident inside their room. S1 expressed that staff are trained to redirect residents’ actions. S2 expressed that there is no lock on residents’ doors and residents can come and go as they please. S2 expressed that A1 provided training on how to redirect residents’ actions (dated 02/17/2023) and there is no need for any resident to be isolated from other residents or staff. LPA Calderon conducted an interview with R1-R3. 3 out of 3 residents expressed that staff has never locked residents inside their room or ever isolated residents from other staff or other residents. 3 out of 3 residents expressed that there is no lock on their bedroom doors, and they can come and go inside the facility as they please. On 07/13/2023 LPA Calderon toured the facility and noted residents moving around from their bedrooms to the living room to watch TV and into the kitchen area. LPA Calderon noted that residents left the facility for doctor’s appointment and day program. On 07/13/2023 LPA Calderon reviewed 4 incident reports dated 11/6/22, 1/17/23, 5/28/23 and 6/25/23. Incident reports do not report R1, or any other resident being isolated from staff. On 07/13/2023 LPA Calderon reviewed needs and service plan for R1-R3. 3 out of 3 residents have health issues. On 07/13/2023 LPA Calderon reviewed training records for staff: Training for verbal communications (dated 6/23/23), which state “STOP” Stop remember to pause, take a few breaths, and refocus, observe your present state without judging it, proceed with awareness and understand. On 09/21/2023 LPA Calderon reviewed ISP plan for R1-R3 (dated 08/04/2023) ISP plan expressed that staff redirect verbally when R1-R3 are experiencing a behavioral episode. Staff will have a conversation with R1-R3 when not following directions. There is no consequence for R1-R3 is non-compliant only redirection. Regarding Allegation #2 : Staff withheld residents’ meals. This complaint alleged facility staff withheld residents’ meals. LPA Calderon conducted an interview with A1. A1 expressed that at no time does staff withhold food from R1. A1 said that staff provide 3 meals per day and snacks. A1 also expressed that R1-R3 provide snacks at day program. A1 expressed that R1-R3 have access to the kitchen and food if they are hungry. A1 expressed that R1-R3 are diabetic and there is a meal plan generated weekly for residents. A1 expressed that staff would not withhold food from residents due to R1-R3 acting out and having to be redirected. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff expressed that staff provide 3 meals and snacks per day and that no resident is denied food for any reason. S1-S2 expressed that R1-R3 have access to the kitchen and can access snacks when they are hungry.