complaint·September 20, 2024

It was alleged that “Facility staff are not keeping the facility at a comfortable temperature for residents” It was alleged that on 12/8/2022 around 7am R1’s room was at 67 degrees Fahrenheit and R1 had expressed being painfully freezing with cold feet despite having a pile of blankets on them. LPA conducted staff interviews which revealed that the facility is kept at a comfortable temperature and the facility has a heater for the entire home. Staff revealed residents are provided with extra blankets upon their request and R1 tended to express being cold and had a heater in their room. LPA conducted (2) resident interviews. Interview with R1 revealed at times the facility is cold and are provided with heaters and blankets from staff when they request it. (1) other resident was interviewed who was unable to provide information due to not being oriented. LPA conducted a visit on 12/16/2022 and observed the facility thermostat read 70 Fahrenheit. LPA observed facility residents had blankets in their rooms and observed the linens available at the facility. Therefore, the allegation is unsubstantiated at this time. It was alleged that “Staff left resident on the floor after a fall for a prolonged period of time”. It was alleged that Resident #2 (R2) was left on the floor of their room after experiencing a fall for hours, despite calling for staff assistance on 12/7/2022. It was alleged staff came and assisted the resident after hours of being on the floor unclothed and had placed a chair on the edge of the resident’s bed to prevent them from falling again. LPA conducted records review of facility incident reports and found no reports had been submitted to the regional office for R2 12/7/2022. LPA conducted (2) staff interviews which revealed staff could not recall an incident were R2 had a fall at night around the incident date. LPA conducted (2) resident interviews. R2 was interviewed who was unable to provide information due to not being oriented. (1) other resident interviewed was unable to recall if R2 fell. Therefore, the allegation is unsubstantiated. It was alleged that “Facility staff grab residents forcefully while changing residents clothing”. It was alleged that on 12/8/2022 R1 had been changed by staff and their arm was handled in a rough manner, where R1 had yelled in pain. LPA conducted (2) staff interviews who denied handling R1 roughly or witnessing any staff handle R1 roughly. Staff reported seeing no injuries on R1 around the incident date. LPA conducted (2) resident interviews. R1 was interviewed who denied the staff handed them in a rough manner. R1 could not recall a time when they yelled out in pain around the incident date. (1) other resident was interviewed who was unable to provide information due to not being oriented. Therefore, the allegation is unsubstantiated. It was alleged that “Facility staff are not ensuring floors are kept clean”. It was alleged that R1 and R2’s room were not kept clean on 12/8/2022, as there was blood that was found on the floor. LPA received photos of red stains on a floor. LPA conducted interviews with (2) staff. (1) staff interview denied seeing any blood on R1 and R2’s bedroom floor. (1) other staff interviewed revealed that R1 and R2’s room was soiled with stains on the floor but was unable to state what the stains were from. This staff reported cleaning R1 and R2’s room when it was dirty, and cleaning the stains. Staff denied R1’s room was dirty for a prolonged period of time. LPA conducted interview with (2) residents. Interview with R1 revealed having no issues with the cleanliness of their room. R2 was interviewed who was unable to provide information due to not being oriented. LPA conducted a walk through of the facility on 12/16/2022 and found the facility floors were clean and did not find debris or blood in any resident room. Therefore, the allegation is unsubstantiated. It was alleged that ”Facility staff do not properly assist resident with toileting needs” It was alleged that R1 had asked staff for assistance with toileting on 12/8/2022, and that staff had told R1 to go in their diaper instead. LPA conducted interview with (2) staff interviews which revealed R1 would refuse to use Hoyer lift to be taken to the restroom safely due to fall risk. R1 required (2) to (3) people to assist in incontinent care and would give R1 the choice to go in their diaper or be taken to the restroom with the Hoyer lift. Staff revealed R1 refused to use the Hoyer lift when asked by staff. (2) staff interviewed denied refusing to take R1 to the restroom and telling them to go in their diaper instead. LPA conducted (2) resident interviews. R1 was interviewed which revealed conflicting information as R1 initially stated that staff do not take R1 to the restroom, then later in the interview stating that staff do take them to the restroom. (1) other resident interviewed was unable to provide information due to not being oriented. LPA conducted interview with (1) outside source which revealed that R1 was witnessed being taken to the restrooms to relive themselves. Therefore, the allegation is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided.