Incident investigation·June 6, 2022

On 06/06/2022 at 11:15am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit to the facility following up on an incident report submitted to the Regional Office on 05/27/2022. LPA was greeted and granted entry by facility administrator Mike Silverman after explaining the purpose of the visit. Administrator states that the incident occurred on a weekend and required his presence back at the facility. Agency caregiver S1 was alleged to have handled resident R1 in a rough manner, and that caregiver would not allow resident to ambulate freely from the bedroom to the bathroom without being in her wheelchair, claiming time constraints and the inability to supervise the resident adequately. M. Silverman interviewed the contracted staff in present of a facility caregiver and additionally reported the incident to the Long Term Care Ombudsman and staffing company, Pioneer Staffing. Administrator indicates that efforts are made to hire permanent staff with 9 new caregivers being onboarded, but that at this time a large number of agency staff is still being needed to fill in with approximately three or four agency staff for every shift on a total of six to eight total caregivers present. The Health Care Department is also making efforts to identify agency staff that are reliable and more qualified in order to prioritize their schedule over other agency staff. LPA also consulted with Administrator to indicate that the preferred procedure to address abuse allegations was to take staff action ensuring the residents' well-being but that investigative actions was as a priority left to the licensing authority to handle. An exit interview was conducted and a copy of this report was printed and left to facility representative.