It was reported that staff have been giving a client cannabis oil that is not prescribed to them.

LPA reviewed a physician’s recommendation that states that Client 1 (C1) has seizures and has decreased seizure activity when they take two tablespoons cannabis oil, so continue using it.

3 of 4 staff stated the facility gives C1 cannabis oil.

Administrator stated when C1 moved into the facility they were already taking the oil to control their seizures.

It was determined that medical documentation is on file. This allegation is unsubstantiated.

Staff pushed resident. - UNSUBSTANTIATED

It was reported that staff pushed a client into their room.

During staff interviews it was learned that during a behavior staff walked Client 2 (C2) to their room.

Administrator stated during a behavior a while ago, C2 went to assault staff, they walked C2 to their room.

It was determined that during a behavior staff walked Client 2 (C2) to their room. There is no evidence that staff pushed C2. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that staff held the door closed to a client room.

LPA reviewed an incident report dated 11/10/2024 that states Client 2 (C2) had an escalated behavior and charged staff trying to hit, grab and pull their hair. C2 grabbed onto staffs’ hair pulling them into their room. Staff left the room and shut the door to give C2 quiet time. Staff heard C2 trying to get out of the window and staff went back into the room and stepped in between C2 and the window.

During staff interviews it was learned that during a behavior staff walked Client 2 (C2) to their room and a new staff member closed the door, held it, but opened it again immediately when experienced staff told the new staff to let go as soon as the new staff grabbed the handle.

It was determined that during an escalated behavior a new staff closed a client’s door but opened it up immediately. This allegation is unsubstantiated.

It was reported that the administrator did not seek timely medical attention for Client 3 (C3).

LPA reviewed an incident report which states on 12/12/2024 the swelling in C1’s face had increased. C3 was taken to the dentist for diagnosis and treatment. C3 would not let the dentist look at their teeth. The dentist requested staff take C3 to the ER to be examined in case C3 had an infection. C3 was taken to the ER at 4:00 PM, examined at 7:00 PM, diagnosed with abscess at 9:00 PM. On 12/13/2024 5:30 AM C3 was transferred to another hospital for treatment with IV antibiotics. Facility staff stayed at the hospital with C3 until their discharge on 12/16/2024.

Staff interviews revealed that C3 showed signs of swelling and discomfort to the mouth on Tuesday 12/10/2024 and C3 was taken in the next day for treatment (12/11/2024).

Administrator stated Staff told them on a Monday (12/09/24) night that C3 didn’t eat their dinner and was holding their face. On Tuesday (12/10/2024), C3 was taken to the dentist who suggested C3 should be taken to the ER in case of infection.

It was determined that on 12/10/24 C3’s face was slightly swollen, C3 was taken to their dentist on 12/12/24 who referred C3 to the ER for treatment. ER transferred C3 to a local hospital for IV antibiotic treatment. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.