Throughout the investigation, the Department interviewed three (3) facility staff (S). Interview statements received from all (3) staff indicated that residents’ family members would purchase supplies such as toiletries, briefs, and wipes and bring them to the facility for resident to use. Interview with S2 indicated supplies such as wipes are being taken from one resident to be used for other residents in care.

The Department requested for a supply log for review. Executive Director, Jasmine Ridenour, stated the facility does not have a written log to keep track of residents’ personal supplies.

The Department has recommended for the facility to create a written log and document down the quantity of each supplies, what supplies are being used, and for what resident.

Allegation: Staff caused injury to resident. – Unsubstantiated.

On 10/11/2020, the facility submitted an unusual incident/injury report to Community Care Licensing. The report indicated that R1 went out on the courtyard and fell out of wheelchair. R1 was bleeding from a cut on the forehead. The facility had sent R1 to the ER for an evaluation. R1 had returned to the community the same day. The facility notified R1’s Responsible Party and Primary Care Physician. The facility had continued to monitor R1 for any changes in condition and care plan updated to monitor resident as a fall risk.

On 10/26/2020, the Department conducted a Case Management visit to follow-up on the incident. The Department requested for R1’s physician report and discharge medical documents.

Allegation: Staff turn off call button. – Unsubstantiated.

Throughout the investigation, the Department interviewed three (3) facility staff (S). The emergency pendants are routed through a central system and sent to notify staff. The staff go to where the pendants are pages and must reset the call button manually.

Throughout the interviews, the Department discovered the caregivers share one pager. Interview with S1 indicated that a NOC shift caregiver that works in the Villa (Memory Care Unit) unplugged the call button system. Interview statement from S2 is consistent with S1. S2 stated morning shift staff must continuously check if the system has been unplugged in the morning. Interview with S3 indicated S3 is unaware that staff is unplugging call button. S3 stated there are times where staff has not responded to resident’s call on time.

*********************Continue on LIC9099-C***************************

Due to the information CCL finds the allegation to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted.

A copy of this report will be provided electronically to Executive Director, Debra Duval, via email. ED to return a signed copy to CCL, a signed copy should be retained for facility records.