complaint·July 28, 2023

The explanation the caregivers gave was that it was for the residents’ personal safety so they would not fall and get hurt and that other staff members did it, so they did it as well. Staff stated that neither the [former] Administrator nor the Assistant ever told them they could not restrain residents or lock residents in their rooms. Staff admitted to locking the residents in their rooms starting at 7:00 p.m. to keep them safe and so they would not wander and go into other residents’ rooms and take things that do not belong to them. The testimony provided by caregivers is corroborated by color photographs which depicted residents restrained in their wheelchairs. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. The violation of residents’ personal rights resulting from the facility locking residents in their rooms was previously cited as a deficiency during a Case Management Visit on 10/7/20. The violation of residents’ personal rights resulting from the facility restraining residents inappropriately was already cited as a deficiency in connection with Complaint Control No. 22-AS-20200714134015 on 11/13/20. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. R1’s family member, Witness #1 (W1), felt R1’s needs were being meet and had much respect for the facility itself. Witness #2 (W2), family member of R2, felt R2’s needs were being met, but did feel R2 was over medicated due to R2 being more wheelchair bound and in bed more on W2’s visits. However, facility Med-Techs were interviewed and denied overdosing residents as they followed the Medication Administration Records (MAR) and documented every medication given to the residents per the log. Family members for Resident #3 (R3) were not contacted as R3 has a public guardian and Resident #4 (R4) and Resident #5 (R5) are under the guide of Department of Health Services. The investigation did not reveal any additional evidence to corroborate these allegations. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.