complaint·February 26, 2024

1. Staff intimidating a resident. It was alleged that R1 was told by the administrative personnel that staff #1 (R1) is being written up for helping R1. During previously conducted interviews, the Wellness Coordinator and Administrator denied writing up S4. S4 was interviewed and denied being written up. R1 was unable to provide specific details to explain who told R1 that S4 will be written up and why? A review of facility records including S4’s file, did not reveal any sufficient information to support the allegation. Therefore, based on interviews and record review the allegation is unsubstantiated at this time. 2. Staff do not repositioned resident It was alleged that staff do not sit up or turn R1. Staff interviews revealed that residents are being repositioned every two (2) hours and after meals. All residents interviewed including R1 did not address any concerns about turning and reposition or transfer assistance. Resident #9 (R9) stated staff never reposition them. However, per resident’s file review R9 is not identified as a bedridden resident requiring turning and repositioning. A review of R1’s record revealed that R1 is non-ambulatory and does not require turning and repositioning in bed. Staff is assisting them to transfer in and out of bed. Based on interviews and record review, there is no sufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. 3. Staff do not assist resident with incontinence needs timely resulting in a rash It was alleged that staff are changing R1 once or twice during a 24-hour time frame causing R1 to have a rash on bottom. Staff interviews revealed that incontinent residents are being changed three (3) to four (4) times a day or as needed. During facility internal investigation, R1 indicated to staff that they were changed, but not by S4. R1 was changed by another staff. Other residents revealed that staff changes them three (3) times a day, and more often if needed. A review of facility incontinent log supported the information provided by staff and residents. No information was available during this investigation to confirm the allegation. Therefore, the allegation is unsubstantiated at this time. 4. Staff are not safeguarding a resident's property It was alleged that staff are taking R1 over the counter medications and ointments. Staff revealed that R1 is the only resident that reports things missing. When residents’ things are missing the policy of theft is to investigate what resident brought and logged in. Staff also revealed that residents are not allowed to keep over the counter medications or ointments in their possession. The medication is distributed to the residents by the facility staff. R1 indicated that they were never given a paper to list their personal items. Other residents revealed that they never had their items go missing. A review of R1’s record revealed that R1 did not report their personal belongings. No supporting information was available during this investigation to verify the allegation. Therefore, based on interviews and record review, the allegation is unsubstantiated at this time. No immediate health and safety hazard is noted during this visit. Exit interview conducted with Resident Care Director, Mary Jane Reyes and a copy of this report was provided.