Facility Evaluation Report

On 12/20/2023, Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20231030114959. LPA met with administrator and explained the purpose of the visit.

During the course of the investigation of the above complaint, staff #1 (S1) reported that he/she witnessed staff #2 (S2) put his/her hand on resident #1 (R1) to stop R1 from hitting, kicking, and spitting at staff. S1 was not able to provide the exact date that the incident happened but stated that this only happened once and there were other staff members present but S1 was not certain if these staff members also witnessed the incident.

As part of the investigation, LPA reviewed documents, LPA interviewed the assistant administrator, the administrator, and staff member including the ones that S1 reported being present during the incident.

According to the administrator and the assistant administrator, they were not aware of this incident and they have not witnessed any staff putting their hands on any residents as they were trained on different interventions to approach residents when they became agitated and combative.

LPA reviewed the weekly documentation that was provided by the facility and completed by a Licensed Professional, there were no bruises, no discoloration, etc. noted for R1.

LPA interviewed 5 staff members and all of them reported that they have not witnessed any staff putting their hands on R1 and other residents. The approaches that they would implement when R1 gets combative and agitated aligned with R1's Appraisal/Needs and Service Plan.

Based on observation, interview and record review, no deficiency is cited.

This report is reviewed and discussed with administrator; a copy is provided.