complaint·August 25, 2022

As to the allegation of, “Facility staff member called resident an inappropriate name.” It was discovered that S3 and R1 were engaged in multiple aggressive verbal interactions at different times during the week of 08/15/22 through 08/22/22. On 08/21/22, One of the aggressive verbal interactions was overheard by S1, who was compelled to intervene and ended this aggressive verbal interaction. S1 stated that S3 was speaking in Tagalog during this specific verbal interaction. R1 is an English only speaking resident and indicated that the other aggressive verbal interactions were spoken in Tagalog by S3. S3 did not admit to using any inappropriate names or profanity and S1 did not recall hearing any profanity in Tagalog (Tagalog is S1’s second language) and R1 is English only language. Based on the interviews, there was not enough evidence to conclude that inappropriate language was used therefore the allegation of, “Facility staff member called resident an inappropriate name.” is unsubstantiated at this time. A personal right finding pertaining to the aggressive verbal interaction is addressed on a separate allegation to this complaint. As to the allegation of, “Resident sustained bruising while in care.” It was discovered through interviews, admission, documentation, and observation that R1 has bruising on their right arm and back of the right leg. R1 stated they were not sure how the described bruising occurred. R1 also stated that Staff at the facility have no issue in transferring R1 from bed to wheelchair and none of the bruising on the arms or legs are from transferring. R1’s Primary second diagnosis is Hemiplegia, unspecified affecting right dominant side. Facility staff have all be trained in patient transfer basic techniques. Based on documentation, interviews, and observations there is not enough evidence to support the allegation of, “Resident sustained bruising while in care.” and is unsubstantiated, at this time. As to the allegation of, “Resident sustained a pressure injury while in care.” R1 stated they have redness on the center of their buttock. R1 stated that the redness was there prior to admission to this facility in July 2022. Facility physical assessment documentation also indicates that R1 had, “redness in buttock area”. No other documentation states that R1 has a pressure injury. Licensee has a doctor’s appointment for R1 scheduled on 08/29/22 at 2:15pm, to ensure an appropriately skilled professional addresses the redness. Based on interviews, admission of R1 and documentation, there is not enough evidence to support the allegation of, “Resident sustained a pressure injury while in care.” and is unsubstantiated at this time. CONTINUED on LIC9099-C As to the allegation of, “Facility staff member does not provide resident with assistance when asked.” It was discovered through interviews, observation, and admission that 3 of 4 residents currently living at the facility that were interviewed had no issues with staff providing assistance at any time during their stay at this facility. R4 was unable to have a meaningful interview due to current cognitive level. R1 stated that staff were always helpful and assisted when requested. A visiting family member of a current resident was interviewed on 08/23/22 and indicated that they have had no issues with the facility in any regard and does not believe their family member (Resident) has ever had their needs not met or been unable to be assisted by staff. S1 and S3 both stated that they are available to all residents while they are at the facility and in very limited circumstances a resident may have to wait for a caregiver to finish with another resident before assisting the request of the next resident. Staffing at the facility is at a 2:1 ratio during the hours of 7:00am until 10:00pm and 4:1 during the hours or 10:00pm until 7:00am. LPA observed residents’ requests for assistance being met during the visit from 8:10am through 1:09pm on 08/23/22. Based on interviews, observations, and admissions there is not enough evidence to support the allegation of, “Facility staff member does not provide resident assistance when asked.” and is unsubstantiated at this time. As to the allegation of, “Facility is not following resident's care plan.” Based on documentation, interviews, admission and observation it was discovered that R1’s Appraisals Needs and Services Plan (LIC625) dated 07/30/22 and Physicians Report (LIC602A) dated 07/27/22 indicated that R1 was non-ambulatory and incontinent and required staff assistance in both areas as it pertains to this allegation. R1 stated that their needs were being met by staff, staff were able to transfer R1 to wheelchair and staff would change R1 at R1’s request. R1 also stated that all other needs were being met by the facility. On 08/23/22 at 8:09am, LPA observed R1’s request to be changed were being met as LPA was initially entering the facility. On 08/23/22, LPA observed S1 transferer R1 into wheelchair and move to the facility patio to allow R1 to smoke cigarettes. S1 and S3 stated that all residents’ needs are addressed in a timely manner, and as needed. Based on interviews, admission, observations, and documentation there is not enough evidence to support the allegation of, “Facility is not following residents care plan.” and is unsubstantiated at this time. Exit interview, report singed, report emailed.