Complaint Investigation Report

S1 stated that R1 denied any sexual acts that have happened while in the facility, additionally, there are no male staff currently or recently assigned to the memory care unit where R1 resides. S1 stated that staff that work with R1 were instructed to monitor who enters or exits R1’s room, staff have not observed any male enter R1’s room. S1 stated that R1 exhibits overt sexual language when R1 is upset which has been a consist behavior from the beginning of R1’s residing at this facility, according to S1 interview on 11/02/2024. On 11/02/2023, LPA interviewed Staff 3-10, (S3-S10), all stated that R1 typically exhibits explicit profanity as a normal behavior for R1 and has refused care giving assistance when upset.. On 11/02/2024, LPA, S1 and facility Administrator conducted an interview with S2. S2 stated that they had a conversation with a staff member about R1 but did not provide any other details about R1 other then what R1 stated, “He raped me”. Based on interviews, observations and documentation, at this time there is not enough evidence to support the allegation of, “Resident sexually abused while in care.” and is unsubstantiated at this time.

As to the allegation of, “Resident sustained unexplained bruising while in care.” It was alleged that Resident had bruises all over their body and look like finger bruises. It was discovered through interviews, observations, and documentation that, on 11/02/2024, LPA Jeffries attempted to interview R1, and R1 was not responsive to basic screening questions. LPA did observe one red bruise on the left forearm of R1 that was approximately 2” with round shape and no indication in the shape that could determine how the bruise may have occurred. On 11/02/2023 LPA Jeffries reviewed R1’s LIC602 (Physicians Report) that indicated a primary diagnosis of Edema. On 11/02/2023, LPA interviewed Staff 3-10, (S3-S10), all stated that R1 typically exhibits explicit profanity as a normal behavior for R1 and has refused care giving assistance when upset. S3-10 stated they have not observed any other bruising on R1’s body other than the left forearm bruise. Based on interviews, observations, and documentation there is not enough evidence to support the allegation of, “Resident sustained unexplained bruising while in care.” and is unsubstantiated at this time.

As to the allegation of, “Staff do not ensure that residents take medication as prescribed.” and, “Staff do not ensure residents’ incontinence needs are met.” It was alleged that staff do not properly administer medication to R2 and R2 “stashed” medication in their drawer as well as R2 left in soiled briefs for extended periods. On 11/02/2023 LPA Jeffries conducted an interview with R2, R2 stated that they have always take medication when provided by staff. R2 denied hiding or stashing medications at any time. R2 stated that staff do a good job with incontinence needs and medications including prescribed ointments as need. LPA observation during interview, noted that no medications or ointments were in R2’s drawers. On 11/02/2024 LPA Jeffries reviewed R2’s LIC602 (Physicians Report) which indicated UTI as a secondary diagnosis.