complaint·April 6, 2022

In regard to allegation #2, Department staff interviewed S1, who stated that the facility has had several residents who have experienced a fall while residing in the facility. S1 admitted that the falls, which resulted in injuries, were not reported to the Department because the residents were on hospice. LPA Williams reviewed the Department’s records which showed that the facility sent several incident reports to the Department from 2017- 2019; however, the last incident report which was recorded by the Department from the facility was on 4/10/2019. Furthermore, LPA Williams retrieved an incident report dated 3/7/2021 while visiting the facility, which noted that R1 had been admitted to the hospital for altered mental capacity and lethargy. LPA Williams did not observe the incident report that logged in the Department’s records. Department staff interviewed S1 regarding the incident report dated 3/7/2021 and questioned why the incident report did not include the several injuries that were noted in R1’s medical records. S1 stated that it may have been an oversight on S1’s part. In addition to the incident report dated 3/7/2021 not being complete, it was also not recorded within the Department’s time frame for reporting requirements. Based on the information and interviews gathered the above allegations 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. Please see LIC 9099D for deficiencies cited. An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to Gonzalez at the conclusion of the visit. (R3) who denied being physically abused by facility staff members. An attempt to interview Resident #4 (R4) was made by Department staff; however, R4 was unable to make a statement. Department staff was unable to interview R2 as a result of R2’s passing prior to the investigation. Furthermore, another witness, Witness #2 (W2), stated that they observed injuries on R2 during a visit to the facility. W2 stated they questioned S1 and S2 of R2’s injuries, to which S1 stated that R2 experienced a fall. S1 was shown the photos of several residents with various injuries. S1 initially stated that Resident #2 (R2) had sustained the injuries as a result from a recent vaccination. However, S1 then changed their story and stated that R2 experienced a fall while at the facility. S2 and S3 both denied that R2 experienced a fall while residing in the facility. At the time of closure of this investigation, there is insufficient evidence to prove or disprove that the injuries to the residents were a result of physical abuse caused by staff members. Therefore, the allegation is unsubstantiated. Based on evidence obtained during the investigation, LPA has determined that the above allegation is UNSUBSTANTIATED; meaning that 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. An exit interview was conducted where this report (LIC 9099) was discussed and a copy was provided to Gonzalez at the conclusion of the visit.