complaint·January 14, 2025

First aid was provided, and the family was notified. R1 was noted to be agitated the previous night. On 06/26/2024, R1 was observed with a new bruise on their left arm. First aid was provided, and the family was notified again. R1 was also noted to be agitated the previous night. During both incidents, when R1 was agitated, they were observed moving their arms and legs rapidly between the sheets and blanket. On 06/30/2024, R1 walked behind their bed and attempted to go out of their window, which caused R1’s leg to become stuck between the bed and a table. No bruising was observed following this incident and the family was notified. On July 7, 2024, R1 was again found with bruising on their left arm. First aid was provided, and the family was notified. R1 appeared agitated in bed before falling asleep. Interviews with four (4) staff members and the Administrator revealed that R1 bruises easily and has been prescribed a cream to apply when bruising is observed. Staff stated that they have never seen another staff member handle any resident roughly. When a resident is observed to be agitated, staff typically speak to the resident in a calm manner, offer them space, and remain within sight until the agitation subsides. Interviews with three out of five residents in care indicated that they have not personally observed staff interactions with R1 during times of agitation, but they have heard R1 scream at night and heard staff trying to redirect R1 in a professional manner until R1 calmed down. Interviews with five (5)responsible parties of residents in care revealed that they did not express concerns about residents sustaining unexplained bruises while in care. They also stated that they did not have concerns about staff failing to notify them of any bruises or injuries. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations, "Resident sustained unexplained injuries while in care" is deemed Unsubstantiated at this time. It was reported that “Staff handled resident in care in a rough manner”, as it was alleged that Staff handled R1 in a rough manner while providing incontinent care. Interviews conducted revealed that on multiple occasions, when R1 had a bowel movement, R1 would reach into their garments, wipe the stool with their hand, and then attempt to smear it on the wall, bedsheets, or on staff. When this occurred, two staff members would provide assistance. Staff would bring in a plastic basin filled with water and assist R1 with placing their hands in the basin to thoroughly clean the stool. Additionally, interviews with Staff #1 (S1) and Staff #2 (S2) indicated that R1 typically did not fully cooperate during incontinent care. Continued from 9099-C However, both S1 and S2 denied ever handling R1 in a rough manner and stated that they made efforts to be as gentle as possible. The LPA’s interview with three (3) out of five (5) residents in care revealed no concerns regarding their interactions with staff. Interviews with five (5) responsible parties for residents in care revealed no concerns about residents being handled roughly by staff. Based on the information gathered during the investigation, the Department has found insufficient evidence to support the allegation. While the incident may have occurred or may be valid, there is not enough evidence to determine whether the alleged violation occurred. Therefore, the allegation that "Staff handled resident in care in a rough manner" is deemed Unsubstantiated. It was reported that " Staff did not accord dignity to resident in care" as it was alleged that staff appeared to be frustrated and irritated when communicating with R1. Interviews conducted with three (3) out of five (5) residents in care revealed that all (3) have never observed staff to speak to any resident in an unpleasant tone. Interviews conducted with four (4) staff revealed that all (4) have never observed any staff speak to any resident in an unpleasant tone. LPA's interview with five (5) responsible parties of residents in care revealed all (5) have never observe any staff speak to any resident in an unpleasant tone. Furthermore all twelve (12) individuals interviewed did not express any concerns regarding the manner in which staff communicate to residents. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations, "Staff did not accord dignity to resident in care" is deemed Unsubstantiated at this time Exit interview conducted and copy of report issued .