complaint·August 18, 2023

Allegation: Staff leaves resident in bed for an extended period of time. It was alleged that Staff left R1 for extended period of time in bed. Per interviews with W2 and W6 confirmed that staff left R1 for an extended period of time. Both direct witnesses confirmed that staff would only move R1 out of bed when there is a visitor in the facility or when W2 requested another staff assistance to move R1 out of the bed. W2 stated that R1 was left alone without food and no changed clothes. Administrator, didn't deny the allegation. Based on information obtained the allegation is deemed Substantiated at this time. Allegation: Staff left resident in soiled for an extended period of time . It was alleged that staff left R1's soiled in their diapers for an extended period of time. Interview with W2 revealed that the facility is understaffed and thus staff would use multiple diapers for one resident so staff won't change R1 as often. Although Interviews with Administrator and staff revealed that R1 would never notify them that they need to use the restroom or when they want change their diaper. R1's medical records indicated that R1 needs assistance with incontinence care. Administrator didn't deny the allegation. Based on information obtained the allegation is deemed Substantiated at this time. Allegation: Staff did not provide adequate food service to resident in care . It was alleged that staff left R1 in their dark bedroom without food. Administrator denied the allegation. However, interviews with direct witnesses confirmed that staff did not provide adequate food service to residents in care. W2 stated that R1 stayed until 11:00 AM without breakfast, and staff wouldn't offer an alternative option when R1 did not like the food. W6 noted that residents would eat only one meal daily without any snacks. W6 mentioned that staff would tell residents to wait so they could combine breakfast and lunch meals. Based on information obtained the allegation is deemed Substantiated at this time. Allegation: Facility does not have adequate staff to care for residents. It was alleged that facility doesn't have enough staff to meet residents needs. Interviews with direct witnesses revealed that facility had 4 residents with only one staff and the Administrator. Direct witnesses confirmed that Administrator would leave the residents with one staff to run errands. W1 stated that Administrator had called for assistance to left up from the bathroom floor. W2 stated that facility has been always understaffed and the administrator was aware and didn't act on it. Based on information obtained the allegation is deemed Substantiated at this time. (Continue on 9099C p.2) Allegation: Staff did not allow resident visitors. It was alleged that Administrator did not allow visitors for R1 . RP stated that on 6/21/23, Administrator asked RP via text message to not visit R1. Although, Administrator stated that her residents had visitors other day. Administrator didn't deny the allegation. Based on information obtained the allegation is deemed Substantiated at this time. Exit interview conducted, citations issued on investigation report 07/22/24 and a copy of this report delivered