complaint·January 23, 2025

In an interview with R1 on 09/16/2024 by LPA Jeffries, R1 did not recall staff restraining R1 at any time. R1 stated that they have lived at the facility “for years”. R1 stated that they feel safe with staff and care at this facility. On 01/22/2025, LPA conducted a phone interview with R1’s Responsible party (F1). F1 stated that R1, had an undiagnosed stroke sometime in R1’s past (as told by R1’s Physician, Dr. Bettencourt) which resulted in R1’s right hand being closed. F1 stated that facility staff attempted to cut R1’s fingernails on the right hand but did not force R1. On 09/16/2024, LPA Jeffries conducted interviews with S4, S5, and S6, and all staff stated that they have never participated or have witnessed a restraint of any resident at this facility. On 09/16/2024, LPA Jeffries conducted interviews with R2, R3, R4, and R5, all stated that they have never been or seen any type of resident physical restraint at this facility. All four Residents stated that they feel safe in this facility and all staff treat them with dignity. LPA conducted a record review of incident reports for the month of September of 2024 and found no account of reported restraints or staff to resident interventions. At this time there is not enough evidence to support the allegation of, “Staff inappropriately restrained resident.” and is unsubstantiated at this time. As to the allegation of, “Staff are not safeguarding resident’s personal belongings.” It was alleged that R1 had lost two sets of R1’s dentures. Additionally, a toothbrush that was dirty and black was found. It was discovered through interviews that on 09/16/2024, LPA Jeffries conducted interview with Facility Administrator, Adam Bramwell, who stated that R1’s Responsible Person (F1) brought to the facilities attention that R1’s dentures were missing. Administrator stated that they instructed staff to conduct a through search in memory care unit for missing dentures, but they were not found. On 01/22/2025 LPA interviewed F1, who stated that they were aware of one set of dentures being missing, they reported to the facility and the facility conducted a search but did not find the dentures. F1 also stated that R1 has had a history of hiding their dentures and sometimes throwing them into the trash and did not dismiss this possibility in this instance. F1 stated that they facility followed through in their responsibility and due diligence to locate the missing dentures. On 09/16/2024, LPA Jeffries interviewed S1, S2, S4, and S5, all had been instructed to search for missing dentures which were not found. Additionally, S1, S2, S4, and S5 were all shown a picture of the dirty black toothbrush, and all stated they had never seen that toothbrush before and would have collected it and notified supervisors if they had seen a toothbrush in that condition. CONTINUED on LIC9099-C On 09/16/2024, LPA Jeffries noted on an inspection of R1’s room one clean toothbrush that appeared to show normal use which was the brand of Oral B, two unused new toothbrushes that were the brand of Colgate, all had R1’s name written on the handle of the toothbrushes, however the dirty black toothbrush, was not a brand name toothbrush nor did it have R1’s name on the handle. At this time there is not enough evidence to substantiate the allegation of, “Staff are not safeguarding resident’s personal belongings.” and is unsubstantiated at this time. As to the allegation of, “Staff are not ensuring resident is showered.” It was alleged that R1 was not getting showers. It was discovered through interviews and documentation that on 09/16/2024, LPA Jeffries interviewed R1, who stated, “Staff take good care of me, I like the staff.” and that their (R1) needs were always met and have never had an issue with care, including bathing and incontinence. On 09/16/2024, LPA Jeffries conducted interviews with S1 and S2 who stated that showers for R1 are offered 4 times per week, and often R1 would refuse showers. S1 and S2 stated that they would let supervisor know and note in the shower refusal log when R1 would refuse shower. S1 and S2 stated that R1 would normally be showered one to two time per week on average. LPA Jeffries reviewed facility documents labeled “Shower Refusal” for R1, which shows that R1 had refused showers on 10 occasions during the time period of August 15 through September 15th of 2024 which is a refusal of 10 of 20 shower days. On 01/22/2025 LPA conducted an interview with F1, who stated that the facility will call F1 who is R1’s responsible party and notify F1 when R1 has a shower refusal. F1 stated the facility will call but not always the same day. At this time there is not enough evidence to substantiate the allegation of, “Staff are not ensuring resident is showered.” and is unsubstantiated at this time. As to the allegation of, “Staff left resident in soiled diapers for extended period of time.” It was alleged that, facility are leaving R1 in soiled diapers for a long time. It was discovered through interviews on 09/16/2024, LPA Jeffries interviewed R1, who stated, “Staff take good care of me, I like the staff.” and that their (R1) needs were met and have never had an issue with care, including bathing and incontinence. On 09/16/2024 LPA Jeffries conducted an interview with S1, S2, S4, and S5, who all stated that residents are monitored throughout the day for incontinence and incontinence is always addressed when needed. On 01/22/2025, LPA Jeffries conducted an interview with F1 who stated, the facility dose a good job with R1’s incontinence and had never had an issue or problem with the facility addressing R1’s incontinence in a timely manner. At this time there is not enough evidence to support the allegation of, “Staff left resident in soiled diapers for extended period of time.” and is unsubstantiated at this time. Exit interview, report read, and report provided.