Complaint·December 19, 2024

S2 shared that R1 was walking in the hallway to the activity room and fell due to trapping on R1s shoe. S2 stated R1 was active and did not know he/she was unbalanced in walking. S2 stated R1 always likes to walk by himself/herself. S2 also mentioned R1 had a fall in his/her bedroom. R1 had a bed alarm sounded and staff came to check immediately. S2 stated staff called 911 and R1 was sent to hospital. S2 and S4 stated staff check residents every two hours. S3 also mentioned that they set up a bed alarm for R1 after R1s fall in October 2023 and arranged a staff to sit in the second floor (memory care unit) where they can directly monitor R1s bed alarm and the door of R1s bedroom. Based on records review, R1 is an ambulatory resident in memory care. On the facility’s evaluation, it was determined under the criteria of mobility that R1 requires stand by assistance into/out of shower for safety reasons. Regarding the allegations of facility staff handled resident in a rough manner and facility staff forced resident to eat, RP observed that a staff grabbed the resident (R2) by the arm and pulled R2 out of his/her wheelchair and forced R2 to eat. According to staff interviews, S1 stated he/she does not know R2. S1 stated he/she helps to feed residents in dinner. S1 denied that he/she forced resident to eat or handled resident in rough manner. S1 stated usually only 2 or 3 residents need to be fed. S3 shared that there are 4 caregivers in the dining room during the mealtime and always two caregivers to help feed the residents. S3 stated caregivers try to feed residents in a gentle manner but resident might try to approach to the food by themselves while caregivers try to feed residents in an unstable way. S4 stated he/she never saw staff handling residents in rough manner. LPA Chiang also interviewed six residents. R3 stated the facility staff are kind to him/her. R3 stated the facility never handled him/her in a rough manner or force to do anything. R4 and R5 stated that they are able to feed themselves. R8 stated he walks to dining room to eat by himself. All residents mentioned that they did not see or hear staff handling residents in a rough manner. page 2 of 3 Regarding the allegations of facility staff did not shower resident and staff did not assist resident with dressing, RP stated that S5 is the only staff who ever showers and dresses R9. During the resident interviews, R3, R4 and R6 stated they receive 2 showers per week and that caregivers help them dress every day. R6 stated he/she does not need to have more shower per week because he/she does not sweat. R5 stated he/she can have shower whenever he/she wants and has no problem for personal hygiene and staff also helps in dressing. R7 stated he/she has 3 showers per week and needs staff assist for showering. R8 stated that staff helps in dressing every day. According to staff members, S2 and S3 mentioned residents get 2 showers per week. S2 also said that if residents need more showers per week, then either the care level changes or needs extra charge. There is also rotation of assignment among care staff every week, meaning staff will be assigned a different resident to provide care for on a weekly basis. This is to allow staff to get to know all the residents under their care. For the allegations of facility and staff did not assist resident with dental hygiene, RP stated that staff make R10 wait to be fed until everyone else has eaten and then they do not brush the teeth afterwards. RP stated R10 “has gone days with leftover food stuck in his/her teeth”. RP also stated R10 has “swollen, bleeding gums” because of it. Based on records review, R10 did have a medical condition that makes it hard for the resident to open his/her mouth wide and responsible parties are aware and even go to the facility everyday to help assist. Even with this condition, R10 is still provided proper dental hygiene. According to resident interviews, R3, R5 and R8 mentioned that staff helps them brush their teeth. R4, R6 & R7 mentioned that they can brush their own teeth. During staff interviews, S3 mentioned that memory care unit residents get mouth care every day in the morning and assisted living unit resident does not need help for mouth care. S4 stated caregivers provide help for all resident's ADLs. Based on interviews, the department has determined that although the allegations 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 allegations are UNSUBSTANTIATED. Report is reviewed and copy is provided. page 3 of 3