complaint·September 8, 2021

Based on interview with fire department personnel who arrived on scene after the 1:26am call, it was determined that R1 was observed to be in a slouching position and needed to be lifted and repositioned in his wheelchair to prevent a fall. Based on interview with R1 and fire department personnel, it was determined that although fire personnel and two staff were in his room at the time, only the fire department personnel provided the necessary lift and repositioning assistance. Additional interview with S3 revealed that staff has previously provided repositioning assistance for resident. A record review of training for activities of daily living (ADL) and transfers revealed that training occurred on 7/1/21 for Staff1 (1) and 1/7/21 for S2. S2 additionally received training on care and supervision on 3/22/21. Based on interviews and record reviews, the preponderance of evidence standard is met, therefore this allegation is determined to be SUBSTANTIATED. Allegation #2: Resident’s were left unattended: LPA conducted interviews with R1, R2, and R3 and reviewed actual hours worked for the period of 8-6-21 to 8-7-21 as well as incident report. Additional interview was conducted with fire department personnel. A review of actual hours worked determined that 2 staff members were on duty during two 9-1-1 calls at 1:26am and 3:08am. Based on interview with fire department personnel it was determined that during the 9-1-1 call visit at 1:26am and 3:08am, the 2 staff members on duty were accompanying fire department personnel in the assisted living section of the facility assisting R1. An interview with R2 revealed that both staff members were seen with fire department personnel in the assisted living section. An interview with R1 revealed that three individuals, one of whom was the fire department personnel were in his room on the assisted living section. Additional interviews with S3 and S4 revealed that a need for additional assistance was not requested during the times of the 9-1-1 calls. Based on interviews and record reviews it is determined that only 2 staff members were on duty during the 9-1-1 calls and while accompanying fire department personnel, left the memory care section of the building unattended. As a result, the preponderance of evidence standard has been met and this allegation is SUBSTANTIATED An exit interview was conducted with Morgan Whinery and a copy of this report and appeal rights were left with Morgan.