complaint·November 6, 2024

Following is a summary of the investigation findings: Regarding allegation, “Staff handled resident in a rough manner” – It was alleged that staff #1 is very rough when readjusting resident in wheelchair. Staff interviewed denied allegation. Staff reported that resident #1 (R1) was a two person assist and anytime staff would attempt to assist, R1 would get agitated and combative. According to staff they would let R1 calm down and would go back to assist and not force resident with anything. Staff recalled an incident (10/25/2023) where R1 slid down in the wheelchair and two staff readjusted R1. Staff expressed that residents are all handled with care and not in a rough manner. Three out of five residents were interviewed and did not report any staff mistreatment or rough handling. Potential witness interviewed did not report any rough handling or mistreatment by staff towards residents in care. R1 was transferred out and admitted to another facility on 11/30/2023 and passed away in 06/2024. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff handled resident in a rough manner” is deemed UNSUBSTANTIATED at this time. Regarding allegation, “Facility staff did not note changes in resident's medical condition” – Information was provided that R1 was moved to another facility on 11/30/2023 and R1 was observed with “several skin irritations on the verge of becoming bed sores”. It was alleged that staff did not note R1’s skin irritations. Review of R1’s facility records and daily notes on 12/04/2023 and 01/09/2024 did not reveal any skin irritation on the verge of becoming bed sores. Staff interviewed did confirm R1 had skin irritation however would get better over time and never developed into a wound/bedsore. Administrator and staff denied allegation and expressed that R1 did not have any bedsores to report as a medical condition. Potential witnesses interviewed could not confirm any neglect towards R1; confirmed small skin irritation to the back however none on the verge of becoming bedsores. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Facility staff did not note changes in resident's medical condition” is deemed UNSUBSTANTIATED at this time. Exit interview conducted and a copy of report was provided.