Complaint Investigation Report

Staff 1 denied physically grabbing or pushing Resident 1 and stated no physical altercation occurred. Staff members interviewed stated they had never observed Staff 1 physically handle residents in an inappropriate manner. No interviewed witness corroborated the allegation that Staff 1 grabbed or pushed Resident 1. The Department made multiple attempts to interview the staff member identified as witnessing the incident; however, the witness did not respond. Based on interviews conducted and information obtained during the investigation, the Department did not obtain sufficient evidence to support that Staff 1 physically handled Resident 1 in an inappropriate manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Staff did not provide adequate supervision to prevent Resident 1 from eloping. LPA interviewed the reporting party, Staff 1, current and former staff members, and conducted an inspection of the facility’s memory care courtyard and secured perimeter. Interviews consistently indicated Resident 1 occasionally exited the memory care unit into the enclosed courtyard or other secured areas of the facility but remained within the facility’s delayed-egress secured perimeter. During the inspection, LPA observed the courtyard was enclosed by fencing with delayed-egress exit gates, preventing residents from leaving the secured grounds without activating the delayed-egress system. Staff interviewed stated Resident 1 did not leave the secured facility grounds and remained within the secured perimeter while outside. The Department did not obtain evidence establishing Resident 1 eloped from the facility or was inadequately supervised. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Staff withheld Resident 1’s personal property. The reporting party alleged Staff 1 took possession of Resident 1’s cellular phone and failed to return it. Staff 1 denied ever taking possession of Resident 1’s phone and stated Resident 1’s responsible party withheld the phone because Resident 1 repeatedly contacted law enforcement. Other individuals interviewed similarly recalled Resident 1’s phone being removed by her responsible party due to repeated calls to law enforcement. However, witness statements regarding the disposition of the phone were inconsistent, LPA was unable to determine who last possessed the device. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Staff did not safeguard Resident 1’s personal property. The investigation did not identify sufficient evidence establishing facility staff failed to safeguard Resident 1’s personal property. Although Resident 1’s cellular phone could not ultimately be accounted for, witness statements regarding the phone’s disposition were conflicting. LPA was unable to determine that Staff 1 or facility staff failed to safeguard Resident 1’s property. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation Staff did not report incidents involving Resident 1 as required. The reporting party alleged facility staff failed to report incidents involving Resident 1, including incidents related to Resident 1 being outside the memory care unit and the missing cellular phone. The investigation determined Resident 1 remained within the facility’s secured delayed-egress perimeter and did not elope from the facility grounds. The Department did not obtain sufficient evidence establishing a reportable incident occurred that required notification to the Department or the resident’s responsible party under reporting requirements. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited today Per title 22 Regulations.

Exit interview conducted with facility Administrator, Nicole Lowe Ciuffo and copy of report provided