complaint·December 7, 2023

It was alleged that due to lack of supervision, Resident #2 (R2) fell and sustained an injury. It was further reported that R2 sustained an injury to the right eye and a fracture in the right shoulder. This allegation was previously referred to Community Care Licensing Division’s Investigation Branch (IB) and assigned to Investigator Douglas Real (Complaint Control # 29-AS-20220906140504). The Department issued Substantiated findings on 02/09/2023. Deficiencies and civil penalties were also issued at the time of the visit; therefore, no citations will be issued during today’s visit. Exit interview conducted and copy of report issued. Regarding allegation, “Staff handled resident roughly, resulting in injury” – The reporting party alleged that staff #1(S1) handled Memory Care residents roughly. It was alleged that S1 pushed Resident #1’s (R1s) wheelchair very hard and R1s shin hit the wheelchair's footrest, which caused a skin tear (date and time of the alleged incident is unknown). It was also alleged that R1 is often bruised or with small unexplained skin tears. Interviews conducted and documents reviewed reflected R1 would be agitated and combative when staff would try to assist; therefore, staff would let R1 calm down and would go back at a later time to assist. Interviews further reflected that staff did not force R1 with anything. Staff also mentioned that R1 would bruise easily; however, did not recall specific injury incident as alleged. LPA attempted to contact Staff #1 (S1) on 11/03/2023 at 3 PM and on 11/6/2023 at 10 PM and 2 PM, however was unsuccessful. Additionally, on 11/02/2023, at approximately 3:30 PM, LPA contacted the Reporting Party (RP) for additional details; however, RP did not have any further details to provide. Moreover, documents reviewed did not reflect the alleged incident/injury. LPA also attempted to interview random residents in the memory care unit, however they were unable to communicate due to cognitive decline. Potential witness/families of residents interviewed did not reveal any rough handling or mistreatment by staff towards residents. 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 roughly, resulting in injury” is deemed UNSUBSTANTIATED at this time. Regarding allegation, “Staff do not ensure resident receives meals” - The complainant alleged that staff do not get R1 up for breakfast or lunch; staff often leave R1 in bed hungry until 01:00 PM. Staff interviewed reported that R1 was receiving hospice services, did not have an appetite and usually did not get up for breakfast. Therefore, R1 was provided with a meal when R1 was awake and ready to eat. Staff interviewed denied the allegation that “staff do not ensure resident receives meals”. Staff reported that all residents are provide three (3) meals a day including snacks in between meals. During initial visit and subsequent visits to the facility, LPA observed the dining room area in Memory Care and observed residents eating. Potential witness/families interviewed did not express any concern with residents receiving meals. 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 “Staff do not ensure resident receives meals” is deemed UNSUBSTANTIATED at this time. (Continue to LIC9099c) Regarding allegation, “Staff leaves residents unattended” – It was alleged that S1 leaves Resident #3 (R3) unattended for 2-hour time periods. It was further reported that staff take resident out in wheelchairs in front of the television then not check on resident for at least 2 hours at a time. Interviews with staff revealed that residents are provided with time to watch television and are checked multiple times throughout the day by staff on the floor. Staff reported that residents are within eyesight when in the common area. Staff stated that if a resident is in the room resident is checked on at least every two (2) hours by staff. Staff interviewed reported that residents are not left unattended and are checked on regularly. Potential witnesses interviewed stated that they have observed staff in the common areas of the memory care unit watching residents. It was reported that staff are observed on the floor in the common areas throughout the day. No issues or concerns were reported at the time of the interviews. 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 “Staff leaves residents unattended” is deemed UNSUBSTANTIATED at this time. Regarding allegation, “Staff do not ensure residents receive showers” - Information was received that memory care unit residents are not being showered regularly. It was alleged that some of the staff aren't offering showers to the residents and are just writing that residents refuse to shower so they don't have to shower the residents. Staff interviewed denied the allegation and reported that showers are provided to residents and if the resident is combative and or refuse, they will not force the resident to shower. Staff interviews revealed that refusal of any services including, but not limited to, shower refusal is always documented. Staff denied the allegation of falsely documenting shower refusal for any resident. Staff reported if a resident constantly refuses to shower it is reported to management and family. During the initial and subsequent visits LPAs toured the facility’s memory care unit. Residents in the common area observed appeared to be clean and dry. Sample shower logs observed during initial and subsequent visit documented residents shower refusal. Other records reviewed at the facility revealed that hospice residents receive showers from the hospice agency twice a week. Potential witnesses interviewed did not report any unmet hygiene needs of residents. 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 “Staff do not ensure residents receive showers” is deemed UNSUBSTANTIATED at this time. Exit interview conducted/No citations issued/ A copy of report was provided.