complaint·September 16, 2021

Regarding allegation " Resident sustained an injury while in care": Review of R1's medical records from R1's hospitalization from their fall at the facility on 11/23/19 revealed that R1 sustained numerous bruises all over R1's body, as well as a facial hematoma which required medical attention. LPA Colvin received photographs of the bruises on R1 as well and confirmed that they covered a large portion of R1's extremities and face. Upon discharge from the hospital, R1 was re-evaluated by their physician and a new Physician's Report (11/27/19) was created, wherein R1's physician noted that R1 had since declined from being non-ambulatory to bedridden, and that R1 would not be able to be out of bed again "for weeks, if at all". Therefore, based on the large amount of bruising sustained by R1 as well as the significant decline in condition after the fall, the allegation of "Resident sustained an injury while in care" is SUBSTANTIATED. Regarding allegation " There are not enough staff scheduled to meet residents' needs": In LPA Colvin's investigation of this allegation, LPA Colvin reviewed facility records including staff schedule, resident roster, and resident alarm calls & response times. LPA Colvin observed that during the late night shift (NOC shift), there are regularly only two caregivers that cover all four Assisted Living cottages, and on several occasions (11/2/19, 11/3/1911/6/19 & 11/12/19) there is only one caregiver to all four cottages during the NOC shift. LPA Colvin additionally learned through investigation that the facility's NOC Medical Technician is utilized to aid the Memory Care caregivers with reliving them of their breaks, but there is no additional relief staff for the NOC caregivers for Assisted Living. Therefore, if no one calls off of work and all staff scheduled are present, while one of the two NOC Assisted Living caregivers take their lunch break, the other must watch over the other's two cottages, totalling for one caregiver to four cottages. LPA Colvin additionally reviewed a sample of the resident alarm calls and response times and calculated the percentage of calls which were not responded to in under 10 minutes. LPA Colvin observed that 100 of 392 calls for a single cottage over the course of 30 days were not responded to in under 10 minutes. LPA Colvin additionally analyzed the shifts in which these longer response times were taking place, and LPA Colvin observed that 41% of the calls which took over 10 minutes for staff to respond to occurred during the NOC shift. Therefore, based on review of staff scheduled and resident alarm calls and response times, the allegation "There are not enough staff scheduled to meet residents' needs" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report and appeal rights were discussed. A copy of this report, LIC9099Ds, and appeal rights was provided to Resident Services Director Barbara Bogoje during the exit interview.