complaint·November 14, 2022

During the subsequent complaint visit, LPA Baptiste toured the facility and observed the resident’s lunch hour. LPA obtained resident roster, staff roster, staff training on resident’s personal rights, Resident #1(R1) physician’s report, R1’s new admit requirements, R1’s hospice information, R1’s personal rights dated 7/20/2020, R1’s physician consultation final report dated 1/16/2018, R1’s Identification and Emergency information, Resident #2 (R2) Hospice information, R2’s personal right’s, R2’s physician report, and R2’s Identification and emergency information. LPA interviewed Residents R3 through R7. LPA also interviewed administrator and Staff S3 through S6. Prior to returning to the facility LPA interviewed Family Members (FM) for resident R1 (FM1) and R2(FM2). LPA interviewed Former staff S6. LPA attempted to interview former staff S2, S7, S8, S9, S10 and S11. LPA interviewed current staff S1. The investigation reveals the following : Regarding "Staff hit residents in care", it is alleged that S1 hit R1. The Administrator and Current Staff interviewed denied the allegation. They stated that staff do not use physical force on the residents and have never witnessed staff hitting a resident. FM1 stated that they have never witnessed S1 hit R1 but have witnessed unexplained bruises on R1 during visitations. FM2 stated they have never witnessed staff hit residents nor has R2 complained about being hit by staff while living at the facility. S6 stated they did not witness staff hit residents. The investigation reveals the following : Regarding " Staff yell at residents in care.", it is alleged that S1 yells at the residents in care. The Administrator and Current Staff denied the allegation. 5/5 residents indicated that staff has not yelled at them at the facility. FM1 stated that they have witnessed a staff yelling at a resident during a visit but cannot recall which resident or staff was involved. FM2 stated that R2 complained that former staff S11 yell at R2. FM2 stated that S11 was confronted and did not deny the allegation. S6 stated that they did not witness S1 yelling at residents. The investigation reveals the following : Regarding "Staff speaks inappropriately to residents in care", it is alleged that S1 called R2 a “bitch” making R2 cry. The Administrator and Current Staff denied the allegation. 5/5 residents indicated that staff has not spoken to them inappropriately. FM1 stated that they have witnessed a staff yell at a resident during a visit but cannot recall which resident or staff was involved. FM2 stated that a former staff (S3) informed FM2 that the staff was yelling at R2 and made R2 cry. S6 stated that they have witnessed S1 and another staff teasing a resident about a deceased loved one. The investigation reveals the following : Regarding "Staff force feed residents in care", it is alleged that S1 forces food into residents’ mouths, to the point that they will start choking. S6 stated that they had witnessed S1 force-feed residents to the point of choking and leaving bruising on the residents. The administrator and the Current Staff denied the allegation. 5/5 residents also denied the allegations stating they can feed themselves and have not witnessed staff force-feeding other residents. FM1 stated that they have not witnessed a staff force feed a resident, but the food served was “watered-down broth, and there was nothing in the fridge”. FM1 stated that former staff reported the S1 slapped R1 when R1 did not eat. FM2 stated that the facility was not feeding R2 enough and R2 lost weight while in care. LPA observed lunch and did not observe staff force-feeding residents at the time of the visit. The investigation reveals the following : Regarding "Staff rough handle residents in care", it is alleged that S2 is abusive and aggressive with residents, that she rough handles residents and throw away the resident's food if they take too long to eat it. Interviews with FM1 revealed that they did not witness staff rough-handle residents but heard from a former staff that residents were being rough handled. FM2 stated R2 reported that staff was rough handling, yelling, and mean to residents. S6 stated S2 rough handled residents. During the visit, LPA was informed that S2 is no longer employed at the facility. LPA was unable to contact S2 for an interview. The administrator and Current Staff denied the allegation. 5/5 residents do not remember S2 and denied the allegation. Based on LPA's interviews, investigation revealed: 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. Exit interview conducted with Laura Hernandez and a copy of this record provided.