complaint·January 3, 2024

From LPA Martinez’ interview with the administrator, the facility was aware of R1’s bruising but not aware of the cause. R1 sustained bruises frequently due to bumping into furniture. LPA Reed’s interviews with Staff #1 (S1) at 10:10 a.m. and Staff #2 (S2) at 10:45 a.m. revealed no information about R1’s bruising but did confirm that R1 was aggressive with staff and bumped into objects in the house. Neither staff recalled R1 having their fingers slammed in a door. S1, S2, and Staff #3 (S3) who was interviewed at 9:15 a.m. today revealed that residents are observed for any physical changes or bruising every morning when dressing and showering. No residents interviewed reported any bruises or seeing bruises on other residents. Based on interviews, no staff or residents knew of causes for R1’s bruising, and nobody recalled R1 slamming their finger in a door. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are pinching residents“ it was alleged that residents reported a staff member pinching them. LPA Martinez’ interview with the administrator revealed staff had not pinched residents and no residents reported being pinched by staff. Four (04) out of four (04) staff and all residents interviewed today revealed staff did not pinch residents. LPA did not observe any pinching during today’s visit. Based on interviews and observations, staff are not pinching residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not notify residents authorized representatives of residents new medical concerns“ it was alleged R1 had redness on their chest and face that were not reported to R1’s representatives. Record review revealed R1’s emergency information form showed Visitor #1 (V1) as their person responsible for financial affairs and Visitor #2 (V2) and Visitor #3 (V3) to be notified in an emergency. R1 had a history of breast cancer noted on their preplacement appraisal. LPA Martinez’ interview with the administrator revealed R1 had redness on their face prior to their admission. Therefore, the administrator assumed R1’s representatives already knew about the facial redness and history of breast cancer. The administrator reported R1’s facial redness to V2. S1 reported R1’s redness on their face and chest directly to V3. The facility treated R1’s face with Neosporin and V3 took R1 to urgent care. The administrator called 9-1-1 for R1’s chest redness and assisted R1 and V2 in getting to the hospital. Based on interviews and record review, the facility properly reported R1’s medical concerns to their representatives. Therefore the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff yells at residents“ it was alleged that staff told residents to shut up when they talked to themselves. Interview with Resident #3 (R3) at 9:30 a.m. today revealed that staff have to increase their speaking volume when talking to residents who are hard of hearing, but staff do not yell at or tell residents to shut up maliciously. Four (04) out of four (04) staff interviewed confirmed staff only yell when a resident is hard of hearing and never tell a resident to shut up. Based on interviews, staff do not tell residents to shut up when talking to themselves. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff sleep during their shift in the day“ it was alleged that a visitor found multiple staff members asleep. It was alleged that Staff #5 (S5) and Staff #6 (S6) were sleeping during a day shift. S1 recalled the incident and stated staff do sleep on their breaks in the back room, however one staff is always awake and observing residents. S1 further stated that S5 was awake while S6 was resting on their break. The administrator also confirmed that S6 was awake while S5 was sleeping on break. The Administrator allows for staff to rest on their breaks in the afternoon. Four (04) out of four (04) staff and all residents interviewed today confirmed they have not witnessed staff sleeping while on shift. Based on interviews, staff do not sleep during the day shift. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed. Exit interview conducted. Appeal rights discussed. Copy of report provided.