Complaint Investigation Report

During today’s visit, the LPA and Administrator conducted a safety check tour at 10:09AM. No immediate concerns were observed at this time. The LPA attempted one (1) resident interview. The following was then determined:

Allegations: “Staff did not ensure resident’s care needs were being met,” “Staff did not adequately supervise resident,” and “Staff spoke to resident in an inappropriate manner.”

It was reported that staff did not monitor Resident #1’s (R1) condition, such as preventing R1 from drinking excessive water or regulating R1’s showers, and that staff were observed sleeping at night. It was also reported that staff spoke to R1 inappropriately, making demeaning comments.

R1 was diagnosed with psychogenic polydipsia and is known to consume liquids when agitated. The Licensee reported that excessive water intake can cause seizures if unregulated. On 09/03/2024, R1’s Conservator requested a Physician to increase R1’s water intake from 2 liters to 3.7 liters per day. R1’s initial water intake restriction upon admission in 2022 was 1.5 liters. The Conservator also expressed a preference for R1 to take showers every three (3) days to control water access; however, this was a personal preference and not supported by physician orders or an intervention plan. Shower logs in the month of April 2025 showed R1 took a total of eleven (11) showers; R1 took four (4) showers between 04/11/2025 and 04/13/2025. While the facility attempted to follow the Conservator’s preference by limiting the number of showers, staff stated that declining R1 a shower would violate R1’s personal rights.

The Licensee acknowledged that R1 occasionally exceeds the suggested water intake amount and will find ways to access water despite having 1:1 staffing. When agitated, R1 would seek water and lock themselves in the bathroom, requiring staff to verbally redirect R1. Staff #1 (S1) and Staff #2 (S2) stated R1 typically returns to the facility from their Day Program with a large soda in addition to another consumed during the Program. The facility is unable to regulate R1’s water intake when they are at Day Program.