Complaint·May 17, 2022

ALLEGATION 2: Staff interviews revealed that when a change in skin condition or visible injury is observed there is a reporting protocol in place. Based on records review of facility Narrative Charting it was observed that staff have noted resident changes or injury as well as increased monitoring. ALLEGATION 3: Interviews and records review were conducted which reveal that R3 is resistive and combative with staff who are assisting in resident daily care. Based on interviews and Needs and Service Plan review, it is documented that R3 at times yells at or becomes agitated at other residents. There were no staff that confirmed ever witnessing R3 abuse or cause physical injury to another resident. ALLEGATION 4: Interviews and records review confirm that residents fall in care. Based on interviews, staff explained the facility fall procedure when a resident is found having fallen. During interview, there were no staff who confirmed or identified specific residents that experience numerous falls without interventions put in place. Records review indicate that Needs and Service Plans note when a resident is at risk of falls, including interventions. ALLEGATION 5: Interviews of staff members reveal that staff have not been observed yelling at residents. Based on interviews, staff report that there are residents that are hard of hearing and someone could interpret this as yelling. Based on interview of the Memory Care Director (MRD) reveals that staff are educated on Personal Rights, which include approach and how to speak to residents effectively. ALLEGATION 6: Interviews and record review of facility Narrative Charting reveal that most of the residents in MC do not use a pendant to call for assistance. Based on interviews, residents in MC do not understand or remember how or when to use the pendant correctly. Staff report that increased resident checks, knowing resident habits and behaviors and encouraging residents to be in common areas help ensure that residents receive assistance when needed. It was observed in facility charting notes that increased monitoring is noted after incidents experience a fall, illness or change of condition. ALLEGATION 7: Interviews and record reviews were conducted and reveal that staff have been educated on how to properly transfer and/or assist a resident up. Based on staff interview, pulling a resident by their arms is not how they are trained. Records review of facility in-service indicates that this education has occurred. SEE 9099-C FOR CONTINUATION ALLEGATION 8: Interviews and record review indicate that there are multiple ways staff can ensure that the resident rooms are free of odor. Based on interviews, there is a House Keeping schedule and assignment for every resident room. A work order can be made to request carpet cleaning and staff have access to cleaning supplies after House Keeping hours. Records review revealed that House Keeping staff maintain and turn in a log that documents that scheduled cleaning has been completed. ALLEGATION 9: Interviews and records review reveal that the facility receives scheduled monthly and “as needed” Exterminator services. Based on interview of the Environmental Services Director (ESD), the pest control provides service to the exterior and interior of the facility, including the kitchen. Along with the monthly pest control service, daily pest prevention measures are in place in the kitchen as well. Records review confirms that monthly service as well as “as needed” pest control services are conducted. ALLEGATION 10: Interviews and record review were conducted. Based on Interview, R4 leaves the facility for scheduled dinner with family weekly. Staff interviews reveal that since Covid “shut downs” R4 has experienced a general decline, increased agitation and anxiety due to missing family visits. Staff interviewed believe that R4 is able to communicate if in pain. Multiple staff members were interviewed, and it was not confirmed that an abuse allegation was reported. Directors interviewed denied that a report was provided to them. Based on interviews and records reviews conducted by The Department, the allegations 1-10 as listed above are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. A copy of this report was provided and an exit interview was conducted with RSD.