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It was stated in detail by staff daily notes, and behavioral reports reviewed by LPA that the facility staff were to follow Resident#1 in crisis and verbally redirect to calm the situation. The behavioral plan instructed the staff to follow the resident at a short distance and redirect the resident during the crisis behavioral incidents. Information from the record review and staff interviews corroborate that the facility staff follow the behavioral plan for Resident#1.
It was reported by Staff interviews that they followed the behavioral plan for Resident#1 in incidents that occurred at the facility. LPA reviewed multiple police reports of incidents involving Resident#1 showing no neglect by staff, but where staff were following the behavioral plan in each incident. LPA was unable to interview Resident#1 because she had passed away after leaving the facility in September 14, 2025, and the LPA was not assigned to the investigation until March 13, 2026.
Regarding the allegations that staff failed to meet residents’ needs, it was reported Resident#1 needs of care wasn't met because the facility was not more restrictive of the care and a higher level of care was needed. The Administrator was working with the family of the Resident#1 constantly trying to have the Resident#1 on medication that would help but the family refused, so the Resident#1 left the facility shortly after because of declining health. Information obtained by staff daily notes reviewed by LPA, staff interviews, and the behavioral plans that were followed by staff reviewed by LPA that Resident#1 needs were worked on according to the behavioral plans of January 2023, and March 2023. It was deemed that the needs were being met.
Regarding the allegations that staff failed to provide a safe environment for resident. It was reported the facility couldn't keep Resident#1 safe outside of the facility during behavioral incidents. Interview with the Administrator revealed that staff were following the behavioral plans during incidents and Resident#1 was kept safe in the facility. Information obtained by staff interviewed, in the staff daily notes, the behavioral plan reports that staff were trained on, Resident#1 was kept safe in the environment according to the behavioral plan.
Based on interviews, record reviews, and observations, the allegations that alleging staff neglected resident while in care, staff failed to meet resident's needs, and staff failed to provide a safe environment for resident are deemed UNSUBSTANTIATED. A finding that the allegations is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
An exit interview was conducted. A copy of this report was provided to Tarsha Foster - House Lead. |