During today’s visit, starting at 10:10 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. Starting at 10:30 a.m. LPA conducted in-person interviews with three (3) staff including the Administrator, and two (2) residents. The LPA attempted to interview three (3) additional residents however was denied or unsuccessful. Starting at 11:20 a.m., LPA conducted a file review on all six (6) current residents along with R1 who no longer resides at the facility. Starting at 12:40 p.m. LPA conducted five (5) telephonic interviews with a relative of R1 who is also listed as their emergency contact, Department of Mental Health Case Worker (DMHCW), Hospital Clinical Social Worker, and two (2) relatives of current residents residing at the facility. LPA attempted to contact R1 however it was noted by R1s relative and emergency contact that R1 does not have a phone and are difficult to get a hold of. LPA obtained copies of pertinent documents relevant to the investigation.

On the allegation Staff hit resident it is the concern of the reporting party (RP) that facility staff hit R1 on the back and shoulder area. To investigate this complaint, LPA conducted in-person interviews with three (3) staff including the Administrator, and two (2) residents. The LPA attempted to interview three (3) additional residents however was denied or unsuccessful. Starting at 11:20 a.m., LPA conducted a file review on all six (6) current residents along with R1 who no longer resides at the facility. Starting at 12:40 p.m. LPA conducted five (5) telephonic interviews with a relative of R1 who is also listed as their emergency contact, DMHCW, Hospital Clinical Social Worker, and two (2) relatives of current residents residing at the facility. LPA attempted to contact R1 however it was noted by R1 relative and emergency contact they do not have a phone and are difficult to get a hold of. LPA obtained copies of pertinent documents relevant to the investigation. Interview with current residents revealed that they have never been hit by staff. They have never witnessed a staff member hit a resident. They did not witness or hear staff hit R1. Interviews with staff including the Administrator revealed that they are unfamiliar and unaware of any staff ever hitting any of the residents. The staff would never hit any of the residents. Staff were knowledgeable in reporting procedures when LPA Mosley asked questions regarding reporting abuse. Interviews with relative and emergency contact for R1 revealed that they are currently unaware of where R1 is at because R1 recently left the hospital and does not have a cell phone.

Report continued on LIC 9099-C PAGE 3...

They did not witness any of the staff hit R1 on the shoulder or back. They have never witnessed any of the staff hitting a resident. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff hit resident is deemed unsubstantiated at this time.

On the allegation Staff yelled at resident it is the concern of the reporting party (RP) that facility staff yelled at R1 because they decided to shower at 4.a.m. To investigate this complaint, LPA conducted in-person interviews with three (3) staff including the Administrator, and two (2) residents. The LPA attempted to interview three (3) additional residents however denied or unsuccessful. Starting at 11:20 a.m., LPA conducted a file review on all six (6) current residents along with R1 who no longer resides at the facility. Starting at 12:40 p.m. LPA conducted five (5) telephonic interviews with a relative of R1 who is also listed as their emergency contact, DMHCW, Hospital Clinical Social Worker, and two (2) relatives of current residents residing at the facility. LPA attempted to contact R1 however it was noted by R1’s relative and emergency contact that R1 does not have a phone and are difficult to get a hold of. LPA obtained copies of pertinent documents relevant to the investigation. Interviews with current residents residing at the facility revealed the staff do not yell at them. The staff at times may need to raise their voice to the residents since some residents are hard of hearing but they are not yelled at. Residents did not see staff yell at R1 and did not witness staff yell at R1. LPA did speak louder as both residents stated they could not hear LPA and ask LPA to speak louder. Interviews with staff including the Administrator revealed that staff do not yell at the residents. At times staff will speak to the residents louder because they can not hear very well. The staff have never yelled at any of the residents and the staff do not yell at the residents. The staff did not yell at R1. Interview with R1’s relative and emergency contact revealed that R1 can be difficult to work with and did not follow the facility rules at time. The relative had a conversation with R1 about the staff’s cultural background and how it can be a factor as to why they may speak louder and may not be yelling. The relative never witnessed any of the staff yelling and never witnessed the staff yell at R1. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff yelled at resident is deemed unsubstantiated at this time.

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On the allegation Staff did not treat resident with respect it is the concern of the reporting party (RP) that facility staff did not treat R1 with respect and entered the bathroom while they were showering. To investigate this complaint, LPA conducted in-person interviews with three (3) staff including the Administrator, and two (2) residents. The LPA attempted to interview three (3) additional residents however denied or unsuccessful. Starting at 11:20 a.m., LPA conducted a file review on all six (6) current residents along with R1 who no longer resides at the facility. Starting at 12:40 p.m. LPA conducted five (5) telephonic interviews with a relative of R1 who is also listed as their emergency contact, DMHCW, Hospital Clinical Social Worker, and two (2) relatives of current residents residing at the facility. LPA attempted to contact R1 however it was noted by R1’s relative and emergency contact that R1 does not have a phone and are difficult to get a hold of. LPA obtained copies of pertinent documents relevant to the investigation. Interviews with current residents revealed that they have not had any issues with showering. The staff do not enter the bathroom while residents are showering. They have never experienced staff entering the bathroom while they are showering. They have never witnessed the staff entering the bathroom while another resident was showering. They have never witnessed staff entering the bathroom on R1 while showering. The staff treat them with respect and dignity. Interviews with staff revealed that they have never entered the bathroom while a resident was showering. The staff respect the residents and give them their privacy while using the bathroom. The staff did not enter the bathroom while R1 was showering. The facility respects all their residents and treats them all with dignity and respect. Interviews with R1’s relative and emergency contact revealed that R1 was always clean and well taken care. They did not witness the facility staff mistreat R1 or deny R1 respect. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not treat resident with respect is deemed unsubstantiated at this time.

No deficiencies were observed or cited during today’s inspection. Exit interview conducted. Report was reviewed and a copy was provided.