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13 | Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced subsequent complaint visit to the facility. LPA met with Administrator Shannon Moore and informed them of the purpose of this visit. During this investigation LPA conducted interviews with staff and residents; obtained supportive documentation for review to assist with determining the findings for the above noted allegation. The following was determined.
Allegation #1 stated that as a result of lack of supervision by staff, inappropriate action occurred between two residents. Upon touring the facility, LPA observed both involved residents, Resident #1 (R1), and Resident #2 (R2) and found that both were in separate secured areas . Staff interviews revealed that R2 only has access to R1 if R2 is escorted by staff. LPA interviewed Law Enforcement and found Law Enforcement’s investigation revealed staff had walked in on both residents as R2 was reaching for the bottom of R1’s shirt, and R2 had their pants off with their underwear on. Upon seeing this, staff made the decision to redirect R2 out of the room. LPA conducted interviews with those same staff members, and adversely, staff relayed that R2 was not seen with R1, and that R2 does not come to R1’s side of the facility without an escort, thus staff provided conflicting accounts of the incident. LPA conducted a file review of R2 and found that R2 likes to hold hands and kiss other residents, and that it was noted that if any behavior is determined as unwanted to redirect R2 away. Interviews with R1, and R2 were possible and attempted; however, due to cognitive impairment, the interviews were not credible. A review of Law Enforcement’s report was conducted, and it did not indicate an assault that had occurred between R1, and R2 due to a lack of supervision. Thus, as a result of the evidence examined throughout the investigation. the allegation was Unsubstantiated.
Information was further reported that on 12/15/2021, residents were left unsupervised while staff were holding an “all staff meeting”, and further, that there was no oversight to several wandering residents. Residents were allegedly seen exposing themselves, and their diapers exposed, being left without their shoes on, residents being force fed, and several wandering residents not being redirected throughout the facility. LPA conducted several interviews with staff who worked during the time of the alleged incident and found that the facility requires staff to participate in “you-pick” meetings, in which these are scheduled in advance on Wednesday’s and are scheduled in the morning, and afternoon to be held in the Resident’s dining hall. This is done so that those who do not have Wednesday’s off can either come in early for their shift or stay later after their shift to attend the meeting. For those who are working, attendance is split between the two meetings to provide supervision of residents. Staff interviews revealed that supervision is never left without staff coverage, even if a meeting is being held as the meetings are held in the Resident’s dining hall in an area that Residents are not using. The staff roster for the meeting that was held on 12/15/2021 was provided by the Facility and was reviewed and revealed that 13 caregivers were present. Additionally, staff schedule for 12/15/2021 was reviewed, and LPA found that of the staff that were attending the meeting, there were 6 staff supervising the residents. Residents congregate in the dining hall where they will eat, do activities, and be supervised.
Through the evidence obtained through interviews conducted, LPA found that this allegation was Unsubstantiated.
A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
An exit interview was conducted, and a copy of this report was reviewed with and provided to Executive Director Shannon Moore along with a copy of the LIC811.
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