Complaint·June 7, 2024

Interviews determined the staff who mixed up R1 and R2 was from a caregiver agency. Staff interviewed stated sometimes agency staff are not reminded to look in resident binders to confirm who the resident is. LPA reviewed residents’ Service Plan, which stated Resident 1 (R1) requires two-person total assistance for transferring, dressing, and toileting. Staff interviewed stated the agency staff failed to follow policy by disregarding the transferring policy of R1. Agency staff toileted, dressed and transferred R1 without assistance and resulted in R1 being returned to wrong room and bed. Staff stated the agency staff worked on their own and did not collaborate with the other facility staff, and had a bad attitude about the incident. Following the incident, facility management decided this agency staff would not work in memory care and later not in the facility at all. Neither staff nor Administrator denied that the incident took place. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview, deficiencies cited 9099-D, report given, appeal rights given. Documents provided indicated in January 2024, the facility had 16 residents in the memory care, 8 of which required two-person assist. During January 2024, scheduled indicated there were two caregivers and one med tech. Effective February 2024, three caregivers and one med tech were assigned. Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Technical Assistance is issued to remind the facility they should adjust their staffing ratio appropriately based on resident’s needs. Exit interview conducted, copy of report issued.