On 02/25/2021, the facility submitted an Unusual Incident/ Injury Report to CCL. The Unusual Incident/ Injury Report indicated that a care staff (S1) witnessed another care staff (S2) twisting R1’s wrist while trying to change R1 on 02/23/2021. The facility had notified R1’s RP and Local Long-Term Care Ombudsman of the incident. The facility also conducted an internal investigation. The Department had received a copy of S1’s written statement of the incident and had reviewed it. According to the written statement, S2 had asked S1 for assistance with changing R1. During the change R1 had become somewhat agitated and tried to hit S2. R1 had hit S2 in the eye and S2 grabbed R1’s hand hard to move it away. S2 appeared to twist R1’s right index finger in the process. According to S1, R1 had cried out in pain and showed S1, R1’s hand. S1 then reported the incident to Med-Tech and the ED during morning stand up.

Interview statement received from S4 indicated there was another incident that occurred in December of 2020. S4 had witnessed S2 physically abuse incontinence Memory Care residents. S4 observed S2 “open hand smacked their hands” and hear residents cry out in pain. S4 also stated S2 would “yank their wrist and grab it hard.” According to S4, the incident was reported to Med-Techs and management. S4 stated a written report was submitted to the facility. The Department had requested for S4’s written statement, but the facility was unable to locate it.

It was discovered that S2 was put on suspension pending an investigation on suspected resident abuse on 02/23/2021. On 03/02/2021, S2 had resigned from the facility.

Allegation: Staff failed to treat resident with dignity and respect. – Substantiated.

The Department had interviewed and received statements from a total of five (5) facility care staff. It was discovered that S2 had verbally abuse residents in care and did not treat R2 with dignity and respect. Interview with S4 indicated, S2 would call R2 “stupid and dumb” while changing R2. According to S4, S2 had verbally abused R2 on multiple occasions. Interview statement from S5 revealed that there were multiple complaints to from other care staff about S2 verbally and physically abusing residents. Care staff notified management of S2’s inappropriate behavior towards residents in care.

Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted, and a copy of the report left at the facility.

The Department interviewed five (5) facility staff and reviewed resident’s (R1’s) records. According to R1’s Physician’s Report, R1 has bowel and bladder impairment. R1 is not able to care for own toileting needs. The Department reviewed R1’s the Level of Care Assessment completed on 11/25/2020, R1 needs assistance with bathing twice per week and grooming including full assist 4-7 times weekly. Interview with staff (S3) indicated that Memory Care residents sometimes refuse assistance with hygiene needs, but the facility staff will follow up with resident later to make sure hygiene needs are made up for that same day. The Department received an interview statement from R1’s Responsible Party (RP). R1’s RP stated the care that was provided to R1 was good.

Allegation: Staff did not provide adequate food service to residents. – Unsubstantiated.

Throughout the course of the complaint investigation the Department conducted interviews with four (4) residents (R). It was discovered three meals a day with a range of items being served to residents in care. Interview statements received from care staff indicated food service provided to residents in care is not adequate. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the report will be sent via email to Executive Director, Debra Duval, and a signed copy is to be returned to LPA.

Due to the information above, LPA finds the allegations to be UNSUBSTANTIATED meaning 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.