complaint·November 14, 2023

Record review of R1’s Individual Service Plan revealed R1 “has poor judgement and needs monitoring for safety. Needs constant supervision” The Service Plan further noted that the facility was responsible for monitoring R1 for changes in condition, repositioning R1 frequently, transferring R1 with 2 staff members, and communicating with physician and family regularly. Email correspondences revealed facility staff observed and reported all injuries to the appropriate parties in a timely manner. Staff interviews revealed that although staff observed and reported the injuries, no staff witnessed or knew of the cause of the injuries. LPA interviewed Staff #1 (S1) at 11:30 a.m. on 04/13/2023, Staff #2 (S2) at 12:00 p.m. on 04/13/2023, and Staff #3 (S3) at 12:15 p.m. on 04/13/2023. S1 and S2 both noticed R1 was closer to their bed rails than usual after the elbow bruising. S2 and S3 stated R1’s facial injury was noticed after their dental appointment. S2 and S3 further noted that they always use 2 staff to transfer R1 as instructed in R1’s care plan, and R1 was monitored at least every 2 hours and daily for changes in condition. No staff observed other residents enter R1’s room. Residents interviewed stated they had not injured anyone nor witnessed any other residents be injured. Residents also mentioned that staff are quick to respond when a resident needs assistance. LPA’s attempts to interview R1 at 12:45 p.m. on 04/13/2023 and at 11:30 a.m. on 09/12/2023 did not yield any pertinent information. Based on record review and interviews, the licensee followed R1’s care plan, and there is not enough information to confirm the allegation is true. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety hazards were observed during the time of this visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.