Incident investigation·June 3, 2021

Licensing Program Analyst (LPA) Steve Chang and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced case management incident investigation, and met with administrator (ADM) Marife Duewel. The purpose of this visit was to obtain additional information on an incident report received by the Department on 06/02/2021 regarding an alleged abuse towards a resident (R1) . During today's visit, LPA/LPM interviewed the ADM, 3 staff (S1 to S3), R1'a private companion and resident (R1). R1's physician report, Appraisal/Needs and Service Plan, nurses' notes, meeting minutes with R1's family were obtained. Based on interviews, on 05/11/21, R1 was noted to have a right knee swelling and later on ruled out by R1's PCP on 05/28/21, R1 sustained a fracture on left leg. Staff and R1's companion stated that were no reported incident happened to R1 on or before 05/11/21. Staff stated that R1 did not have a fall since admission to the facility. R1 is bedridden who is not able to reposition in bed who is dependent on all ADLs (Activities of Daily Living) except needs assistance in feeding. R1 needs assistance with transferring to and from bed/chair. R1 was observed and interviewed but not able to respond questions due to neuro-cognitve disorder. Staff denied allegation of physical elder abuse. Based on available information gathered during today's investigation, LPA conducted observations, records reviewed, and interviews, the Department found that the above incident is UNSUBSTANTIATED . There is not a preponderance of evidence to prove that the incident of elder abuse or neglect did or did not occur. No citation was issued today. Exit interview conducted with ADM. Due to technical issue, a copy of this report was electrically emailed to ADM for signature.