On 7/27/22, the facility listed above self-reported an incident of suspected abuse on a Report of Suspected Dependent Adult/Elder Abuse (SOC 341). In the Report, the facility lists Staff #1 (S1) as having abused Resident #1 (R1) psychologically/mentally. It explains that, on 7/21/22, facility staff informed management that they had witnessed S1 covering R1’s mouth and on a separate occasion placing a washcloth over R1’s mouth “in order to quiet R1.” The date of the incident was not specified as administrator states that staff who reported it could not recall the exact date, only that it happened 2-3 months ago. To investigate, LPA interviewed the administrator, nurse consultant, credible witness, and staff, and reviewed records.

On 8/2/22 at 10:30 am, LPA interviewed Cindy Baker, Administrator, and Donna Pieprzycki, RN/Nurse Consultant. Nurse Consultant stated that there was a conversation on 7/21/22 among Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4) regarding S1. She states that staff brought concerns to the administrator and her regarding S1’s behavior. She says she did not notice any of S1’s behavior prior to 7/21/22, only that S1 was sometimes “irritated with S1’s mom because she takes care of everything.”

On 8/2/22 at 10:46 am, LPA interviewed Staff #2 (S2). S2 states that R1 was yelling and crying when S1 and S2 were doing a brief change. S2 says they witnessed S1 “covering R1’s mouth with S1’s hand, then place a wash cloth from R1’s chest and put it on R1’s mouth for 1-2 seconds.” S2 says a few minutes later, they witnessed S1 whisper in R1’s ear “you are ugly.” S2 immediately told S1 “don’t do that” and told S1 to get away from R1 which S1 did.

Continued on 809-C

On 8/2/22 at 12:15 pm, LPA interviewed Staff #5 (S5). S5 states that they trained and worked with S1. S5 says they never reprimanded S1, but that S5 was on top of S1 to ensure S1 was doing their job. S5 says that S5 immediately addressed anything that S1 may have been doing wrong so S1 could correct it. S5 stated that S1 never “would do it (treat a resident poorly) in front of me.” S5 says S1 told S5 about S1’s personal problems, and that S1 was “frustrated.”

On 8/2/22 at 12:30 pm, LPA interviewed Staff #6 (S6). S6 states that S6 helped train S1 and that “sometimes S1 wasn’t doing anything while R1 was crying or screaming.” S6 says “I had to tell S1 to help R1.” S6 explains that as soon as S6 addressed it with S1, S1 went “right away and helped R1.”

On 8/10/22 at 9:33 am, LPA interviewed Staff #3 (S3). S3 describes a situation that happened “On a Saturday, about two to two and a half months ago.” S3 explains that R1 was “having a tantrum when we showered R1, and R1 was very tense.” S3 says that S1 was assisting, and “R1 was screaming. S1 put water on R1’s face to stop screaming and yelled ‘R1 knock it off, R1 knock it off, there’s nothing wrong.’” S3 says that later R1 was in their wheelchair and R1’s hands were “wailing.” S3 says S1 “cupped S1’s hands and placed them on R1’s belly, like doing CPR, to make R1 stop arching.” S3 states they do not believe S1 is a threat to R1, only that “S1 gets stressed out and something switches in S1, S1 snaps.”

On 7/28/22 at 9:57 pm, LPA was informed that a credible Witness #1 (W1) spoke with S1 on 7/28/22. W1 states that “S1 admitted to verbal abuse and stated that S1 was kidding around and understands that it was inappropriate. S1 denies any physical abuse, clearly understanding the ramifications of that.”

On 8/10/22, LPA reviewed statements written by S2, S3, and S4. The statements were written on 7/21/22 and corroborate interviews LPA conducted with S2, S3 and S4.

Based on the evidence obtained, residents were not physically injured by S1, however, the facility did not provide safety measures to ensure residents in care were treated with dignity by staff. Deficiency cited on a LIC 809-D.

Exit interview conducted, deficiency cited, and the report and Appeal Rights emailed to the administrator and nurse consultant.