complaint·April 13, 2023

R1’s responsible party’s interview also revealed R1 was always asleep, and they have to wake R1 to feed, as R1 does not stay awake. On 03/02/23, LPA observed R1 sitting in a chair in the dining room area asleep. LPA made several attempts to wake R1 up, R1 would open their eyes and look at LPA then go back to sleep. LPA also observed staff waking R1 up multiple times to feed R1, while R1 continued to fall back asleep, R1 only took a couple bites of food. LPA observed R1 was able to move their limbs to feed themselves but chose to sleep. Staff interviews revealed they are providing R1 with meals and feed R1. However, due to R1’s continued sleeping they also provide Ensure for nutritional value. Staff also confirmed R1’s husband comes to the facility daily and also has difficulty getting R1 to eat. Interview with R1 was unsuccessful. Resident interviews revealed witnessing R1 sleeping and staff repeatedly waking R1 up to eat. It was also alleged, staff are sleeping during working hours. It was reported Staff #1 (S1) was sleeping during the NOC shift, 10pm-6am, in a vacant resident’s room. Staff from different shifts were interviewed and stated not being aware of S1 sleeping during working hours. Outside source interviews revealed S1 was using an empty room to sleep and bring guests, and the residents located in that area were scared. Resident interviews revealed not being aware of staff sleeping on the NOC shift since they are asleep. It was also alleged, staff speak inappropriately to residents. It was reported a staff, name unknown, said curse words to Resident #2 (R2). Outside source interviews disclosed witnessing a staff member, staff name and date unknown, say inappropriate words to R2. Resident interviews denied staff speak inappropriately to residents. Staff interviews confirmed not witnessing staff members speak inappropriately to residents. R2’s interview confirmed they were not spoken to inappropriately. It was also alleged, staff forced resident to shower. It was reported staff are forcing Resident #3 (R3) to shower, while R3 was saying stop and expressing they did not want to shower. R3’s Physician’s Report dated 08/01/22 indicated R3 has a Major Neurocognitive Disorder, aggressive behavior, able to feed themselves, and required assistance with bathing. R3’s Service Plan dated 03/02/23 indicated R3 required extensive physical assistance with bathing along with encouragement to bathe. It also indicated R3 is verbally aggressive, demanding, uncooperative and disruptive. Outside source interviews disclosed witnessing staff force Resident # 3 (R3) to shower, while R3 was saying stop. Further outside source interviews indicated staff would force chocolate into R3’s mouth to get R3 to stop yelling and shower. Continued on an LIC 9099C. R3’s responsible party’s interview confirmed R3 does not like to shower, which has been a lifetime problem and it is difficult to shower R3. R3’s responsible party admitted they send chocolates to the facility to entice R3 to shower. R3’s interview was unsuccessful due to their Major Neurocognitive Disorder. Staff interviews exposed R3 does not like to shower and R3 will hit staff. Staff also confirmed chocolate is provided as an encouragement to shower. It was also alleged, staff forced food into resident's mouth. It was reported chocolates are being forced into R3’s mouth in order to get R3 to shower. Outside source interviews stated staff will put chocolate in R3’s mouth, while showering R3 in order to get R3 to stop yelling. R3 was heard yelling “stop, stop, I don’t want a shower.” R3’s responsible party admitted they send chocolate to the facility to entice R3 to shower. R3’s responsible party explained it’s necessary for R3 to shower for hygiene purposes. Therefore, they agree with giving R3 chocolates to persuade them to shower. R3’s responsible party denied staff are forcing the chocolates in R3’s mouth, as R3 is capable of placing the chocolates in their own mouth. Staff interviews confirmed R3 does not like to shower and becomes aggressive due to not wanting to shower. Staff will give R3 chocolates, while showering R3 in order to get R3 to cooperate. Staff denied forcing food into any residents mouths. Also, as mentioned above R3 requires extensive physical assistance with bathing along with encouragement to bathe. Lastly, it was alleged, staff did not ensure resident's privacy. It was reported residents are not afforded privacy when being changed or showered. Outside source interviews revealed staff are changing resident’s clothing in front of other residents and residents are being showered with the doors open. Staff interviews revealed they will change a resident with another resident in the room. However, they ensure privacy by using their own body to shield the resident. Staff also stated they will use a sheet to shield the resident’s privacy. Resident interviews confirmed staff are affording the residents privacy with direct personal care. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Wellness Coordinator, Jenna Purnell whose signature below confirms receipt of these rights.