Facility Evaluation Report

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation. During the complaint investigation for the complaint 26-AS-20240315163012, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met Holly Suiter - Executive Director/Administrator.

On November 21, 2024, LPA Monter interviewed staff S5-S10. All staff interviewed stated R1 has the behavior of trying to enter other residents’ bedrooms. S5 & S8 stated since R1 moved into the facility, he/she has had the behavior of attempting to enter residents’ bedrooms. S5 - S10 stated staff are supposed to redirect R1 if he/she is trying to enter another resident’s bedroom. S5 – S10 stated staff are supposed to lock resident bedroom doors to prevent other residents from entering their bedrooms.

LPA observed a resident attempting to enter his/her bedroom but was unable to unlock the door. LPA was interviewing Staff S5 in the hallway when this happened. Staff S5 had already clocked out and when he/she went to ask for a staff members assistance to help the resident enter her bedroom. Staff S9 was brought by staff S5 and unlocked the bedroom for the resident. LPA observed the staff locking bedroom doors and unlocking residents bedroom doors when residents wanted to enter.

On November 27, 2024, LPA Monter interview staff S2-S3. S2 & S3 stated R1 has the behavior of entering other residents’ bedrooms. S2 and S3 stated staff are supposed to lock residents bedroom doors.