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32 | [Continued from LIC 9099]
R1 was a resident at the facility with a diagnosis of Dementia and resided in the facility's secured Memory Care (MC) unit. Per file review of R1's records, R1 moved into the community in early May 2026, thus the date indicated in the complaint report (3/27/26) could not have occurred. As there is a possibility the date could have been a typo by the intake analyst at the Department, LPA investigated for the date of May 27th, 2026 as R1 was present at the facility during that time period.
Interviews with multiple staff members revealed that at move-in, R1 exhibited behaviors of exit seeking and was not easily redirect-able, often becoming aggressive towards staff attempting to redirect R1. Review of R1's assessment and service plan (dated May 2026) noted that R1 "may have difficulty with new environment," as well as a noted history of wandering/elopement and medication refusals. R1 was also noted to display resistant and argumentative behaviors towards staff assistance. Review of R1's physician's assessment, dated for April 2026, also noted R1 had behaviors of elopement and expressions of frustration. Staff members interviewed revealed that none had heard or seen any staff physically redirecting R1 at any point, including S1, who was also interviewed. Staff members explained that the way they redirect R1 from exit seeking is to talk with them and offer alternative activities. Interview with MC unit managerial staff revealed that they teach staff to give R1 space and monitor from a distance. It was also added that R1 had been noted to physically grab at staff, though not always in an aggressive manner.
Per file review of incident reports for R1, R1 was hospitalized in the end of May 2026 for behavioral changes and per staff interviews, medications were adjusted. Staff interviews revealed that since returning, R1's behaviors have improved and a private companion was hired temporarily to monitor R1 closely as they adjust to the updated medication regimen. Interview with R1 and other residents revealed no concerns for their care or safety at the facility. Interview with an outside source who partook in R1's care and supervision needs revealed no concerns about staff treatment to R1 and care provided, though they did mention that they felt there should be more staff scheduled in the MC unit. Care staff in the MC unit who were interviewed shared no concerns about the number of staff scheduled and shared they felt there were enough to effectively meet resident needs.
Based on interviews and records review, while the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred – therefore the allegation has been determined to be UNSUBSTANTIATED. An exit interview was conducted with Assistant Executive Director Grochowiak to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents. |