complaint·October 6, 2022

On 9/29/22 at 12:03 pm, LPA visited the facility and observed three staff caring for four residents. Staff assisted residents with lunch and cleaning-up after lunch. Residents appeared to be taken care of by staff who assisted with their needs. On 9/29/22 at 12:16 pm, LPA interviewed Staff #1 (S1). S1 says that there are always three staff working in the facility when all residents are present. S1 says that when R1 was in the facility, S1 witnessed “R1 leaning in their chair sometimes and staff and I propped R1 up with pillows.” At 12:47 pm, LPA interviewed Staff #2 (S2). S2 says that most of the time, R1 was in pain and sometimes R1 was in a wheelchair, sometimes in bed. S2 explains that R1 was weak and leaned in their wheelchair or recliner. S2 says they placed pillows to prop R1 up. A 12:55 pm, LPA interviewed Staff #3 (S3). S3 says that sometimes R1 was in a wheelchair and other times in bed or a recliner. S3 says R1 was “losing balance and leaning in the chair.” S3 says when R1 leaned in the chair, S3 and staff put pillows behind or beside R1 to hold R1 up. S3 says they sat, most times, in the living room watching over residents in addition to checking on them at least every 20-30 minutes. At 1:14 pm, LPA interviewed Staff #4 (S4). S4 says R1’s health went up and down and that “R1 sometimes was sliding out of the chair, then I would prop R1 up, then place pillows on R1’s side(s).” S4 says that R1 was more stable in the recliner and didn’t lean as much. On 9/30/22 at 11:24 am, LPA spoke with a credible Witness #1 (W1). W1 says they visited the facility in December of 2021 and did not witness R1 slumped in their chair nor did W1 notice anything out of the ordinary. On 10/05/22 at 3:22 pm, LPA spoke with a credible Witness #2 (W2). W2 states that the times they have gone to the facility, the facility had adequate staffing, staff appeared engaged and helping and in a couple cases over-staffed. W2 says “I do not see the staff sitting around talking, they are not on their cell phones. I think it is a very demanding and hands-on environment.” Based on the evidence obtained, the allegation “Staff not providing adequate supervision to resident in care,” is deemed Unsubstantiated at this time. Interviews and observations reveal that staff are assisting residents’ needs and in a timely manner. Exit interview conducted and a copy of the report emailed to the Executive Director and Supervisor.