complaint·June 6, 2022

The investigation revealed the following: Regarding the allegation: Staff are inappropriately confining resident to their bed. “ It’s being alleged that a resident is not allowed to get out of their bed and staff will block resident with a chair.” During interviews with residents: 1 out of 6 confirmed this allegation to be true. 3 were unable to confirm due to their cognitive abilities and 2 confirmed the allegation to be false. On 06/06/2022 at 10:10am, R1 states, “I have to say yes, I know about that allegation. It’s for R2’s safety. If R2 gets up in the middle of the night they are going to fall and hit their head. On 06/06/2022 at 10:15am, R2 denies ever being forced to stay in bed. “No, they don’t force me to stay in bed. I never have any problems like that. They never block me in.” R3-5 were unable to interview due to their cognitive ability. On 06/06/2022 at 10:31am R6 states, “I’m able to get out of bed either way. Sometimes they help me out or not. Just depends on how busy they are.” During interviews with staff, 3 out of 3 confirmed the allegation to be false. On 06/06/2022 at 10:46am S1 states, “we don’t block R2 in but because they use a wheelchair, we leave it there sometimes. It’s not blocking. A chair was there because R1 sometimes wants to eat on their cabinet in their room. It doesn’t stay there.” On 06/06/2022 at 10:52am S2 states, “R2 cannot walk alone. They don’t try to get out of bed, and they are never blocked in. Sometimes R1 will call us saying that R2 is trying to stand up but that is not really the case.” On 06/06/2022 at 10:59am S3 states, “R2 is never confined to their bed. We wake them up at 7am and take them to the bathroom. After, we bring them to the table to eat. They sit in the living room most of the time until they request to go lay down.” During interviews with witnesses, 2 out of 2 confirmed the allegation to be false. On 06/06/2022 at 12:37am W1 states, “I was at the facility last week and I want to say no I have not seen R2 confined to their room. When I walk through, they’re usually in the living room or at the table. Not confined to their bed.” On 06/06/2022 at 12:41am W2 states, “R2 is not being confined to their bed. Not that I know of, that’s more false. Every time I go, they are out and either at the table or watching TV in the living room. I’ve never observed staff block them in.” Regarding the allegation: Staff did not prevent resident from stealing another resident’s food. “ It’s being alleged that a resident steals food and drink from another resident.” 0 out of 6 confirmed this allegation to be true. 3 were unable to confirm due to their cognitive abilities and 3 confirmed the allegation to be false. Cont. on 9099C On 06/06/2022 at 10:10am, R1 states, “R2 has never stolen food from me. It’s not so much food, it’s just stuff. If I put something away, they will be after it. I keep my snacks in this cabinet, yes, but they can’t get to it. I stop them from taking my stuff.” On 06/06/2022 at 10:15am, R2 denies the allegation. R3-5 were unable to interview due to their cognitive ability. On 06/06/2022 at 10:31am R6 states, “There are no residents that steal food.” During interviews with staff, 3 out of 3 confirmed the allegation to be false. On 06/06/2022 at 10:46am S1 states, “R2 never takes anyone’s food. Not even their roommate.” On 06/06/2022 at 10:52am S2 states, “I’ve never seen R2 take anyone’s food. R1 doesn’t say anything about that either.” On 06/06/2022 at 10:59am S3 states, “no, never seen or heard R2 taking food from R1 or anyone.” During interviews with witnesses, 2 out of 2 confirmed the allegation to be false. On 06/06/2022 at 12:37am W1 states, “no, I’m not aware of anyone having their food stolen. When I do my visits, they are usually unannounced.” On 06/06/2022 at 12:41am W2 states, “no, I’ve never known R2 to steal anything. Especially food, they are more of a slow eater so if they were stealing, staff would catch them. In fact, R2 had a physical and lost weight so if they were stealing food that would be more of a weight gain than lost.” On 06/06/2022, LPA observed R2 in the living room during inspection. LPA did not observe any chairs or items that could be used to block or confine a resident to their bed. LPA observed the wheelchair of R2 in the living room beside resident. LPA did not observe any electrical extension cords connected to another. LPA reviewed the physician report and needs and services plan for R2 which indicates resident’s non-ambulatory status and the support of the facility to get in and out of bed with staff assistance. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. 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. An exit interview was conducted, and a copy of the report was given.