This complaint alleged that due to staffing issues R1 had an unexplained injury while in care. A1 indicates that A1 received notice from staff that R1 had an unexplained bruise to R1 right arm. A1 indicates that on 03/22/2024 R1 husband W2 took R1 for a walk. R1 appears to have fallen and injured R1 right eye and arm. A1 indicates that W2 did not inform A1 of the fall and injury and the next day staff noticed the injury and reported the incident to R1 family and wrote an incident report. A1 indicates that there are no staffing issues. S1 indicates that any injury to a resident is reported to resident family and an incident report is generated. S1 indicates that there are no staffing issues and the unexplained injury to R1 was not from lack of staff. R1 no longer lives at facility and could not be interviewed. R2 was non-verbal and could not answer any questions. R3-R5 indicates no staffing issues and staff take care of their medical needs. W1-W2 indicates that R1 had an unexplained injury under care from the facility. W1-W2 indicate that R1 injury was due to staffing issues.

Regarding Allegation #2: Staff did not address residents change in condition. This complaint alleged that staff did not address R1 change in health condition. A1 indicates that R1 health was changing and A1 had a conversation with R1 family and that a review would be needed. A1 indicates that R1 was aggressive with staff due to health condition and new medication would be needed. S1 indicates that R1 change in condition was addressed and S1 advised A1 and R1 family of R1 health changes. R1 moved and could not be interviewed. R2 was non-verbal and could not answer any questions. R3-R5 indicates that staff does keep records and address changes in their medical condition. W1-W2 indicate that staff did not address changes in R1 condition and R1 family had to complain. Reviewed R1 records which indicate: Review letter from administrator to residents’ family (date 3/26/2024), letter indicates injury to resident right eye lid, appears resident hit herself on unknown object and did not inform staff. Reviewed email from A1 regarding R1 (date 12/12/2023) regarding reassessment and level of care for resident. Email communications also regarding diet and care.

This complaint alleged that staff did not report incident involving R1. Reviewed incident report which indicates: Reviewed incident report (date 3/22/2024) for R1, on 3/22/2024 at 3:20pm it was noticed by W2 that resident had a slight bruise over R1 right eyelid. R1 had been prescribed a new medication that it was making R1 a bit drowsy, and it was reported to the medical doctor on Monday 3/18/24 and time of dosage was changed per medical doctor and family was informed. Per medical doctor observations it looks like R1 bumped R1 against something and did not say anything to staff. A1 indicates that all staff are trained to generate an incident report for residents in care. A1 indicates that on 03/24/2024 R1 and W2 were walking and R1 had a fall. A1 states that once A1 staff noticed the injury to R1 they reported the incident to R1 family and generated an incident report. S1 indicates that any injury to a resident is reported to Administrator and resident family and if needed 911 is called and resident is cared for. R1 no longer lives at facility and could not be interviewed. R2 is non-verbal and could not answer any questions. R3-R5 indicate that staff do report any incident to their family.

Regarding Allegation #4: Staff handled resident in a rough manner.

This complaint alleged that staff handled R1 in a rough manner. Reviewed letter from A1 to R1 family which indicates: Review letter from A1 to residents’ family (date 3/26/2024), letter regarding injury to resident right eye lid, appears resident hit R1 on unknown object and did not inform staff. Reviewed email from A1(date 12/12/2023) regarding reassessment and level of care for resident. Email communications also regarding diet and care were noted. A1 indicates that R1 health had changes and R1 was aggressive. A1 indicates that R1 was injured with an unknown object and did not advise staff. A1 indicates that staff would not handle R1 in a rough manner. S1 indicates that R1 health had changed and was more aggressive. S1 indicates that staff would redirect R1 aggressive actions and would never handle R1 or any other resident in a rough manner. R1 could not be interviewed and R1 no longer lives at facility. R2 is non-verbal and could not answer any questions. R3-R5 indicate that staff have never handled them in a rough manner.

This complaint alleged that staff are not trained to care for R1. Reviewed training log notes which indicate: Staff are given training in 16 different topics from dementia training to client’s rights to reporting. A1 indicates that all staff are given training every 3 months and no staff would be allowed to care for resident without training. S1 indicates that staff are provided training every 3 months to include dementia care, reporting, clients’ rights.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “resident sustained unexplained injuries due to lack of staff supervision” “staff did not address residents change in condition” “staff did not report incidents involving resident” “staff handled resident in a rough manner” “staff are not adequately trained to care for residents” is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Bessie Coello (A1).