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32 | The investigation revealed the following: regarding the allegation “Facility staff are not preventing a resident from harassing other residents.” It is alleged facility staff are not preventing a resident from harassing other residents in care. On 05/29/2025, LPA Ramirez interviewed staff and residents. Five (5) out of seven (7) resident interviews revealed R4 makes inappropriate comments towards residents, yells at other residents’ and has blocked a resident from access to parts of the facility. Resident interviews also revealed that staff intervene and address the situation. Three (3) out of the three (3) staff interviewed denied the allegation. Two (2) out of the three (3) staff interviewed revealed R4 does have inappropriate behavior towards staff and other residents, however staff intervene and redirect R4. One staff member reported that R4 has been spoken to regarding violating house rules and R4’s physician is notified of any incidents involving R4. On 05/29/2025, LPA Ramirez conducted a review of residents and unusual incident reports dated 01/15/25, 03/06/25, 04/15/25, 04/30/25, 05/15/25, 05/16/25, 05/21/25, written warnings dated 05/25/22 and 06/06/22, Incident Report Short Forms dated 05/08/22, 05/12/22, 05/22/22, 05/19/22, 06/01/22, 06/03/22, 06/06/22, 06/08/22, and the Residency Admission Agreement dated 06/02/2021, including facility house rules. The investigation revealed that R4 was admitted to the facility in June 2021, and since being admitted to the facility, R4 has exhibited inappropriate behaviors, such as making inappropriate remarks and/or sexual comments to other residents’, verbally abusing residents, throwing liquids/food on the floor, and preventing a resident from accessing parts of the facility. On 06/15/2022, staff met with R4 to discuss R4 inappropriate behavior towards staff and regarding R4s violation of the house rules due to smoking in residents’ room. On 06/06/22, the facility issued a written warning to R4 not verbally abusing staff. On 05/22/22, the facility issued a written warning to R4 not following the house rules as R4 was yelling at staff and throwing food onto the facility floor. Review of the House Rules which are part of R4s signed Residency Agreement dated 06/02/21, indicate that residents are to respect others in the community, including other residents, visitors and employees. However, the Residency Agreement/House Rules do not indicate what the facility will implement if a resident breaks the House Rule. Staff address R4’s behaviors and staff are intervening when issues arise between residents’ and R4. 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, therefore the allegation is UNSUBSTANTIATED.
Exit interview conducted and a copy of this report was provided via email.
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