It was alleged that Resident #1 (R1) and Resident #2 (R2) fell, sustaining bruising, when facility staff did not check on the residents during the overnight shift. Record review revealed that R1 had a fall on 11/08/2020 at 06:51PM. Incident report indicated that R1 was at the dinner table when R1 got up from their wheelchair and fell in the dining area. R1 sustained a skin tear on the left side of their forehead. Incident report indicates that R1’s physician was informed of the incident, staff cleaned the injury, and R1’s physician visited the following morning. Interview revealed staff were present in the dining room and the adjacent kitchen area when R1 fell. Additionally, staff recalled R1 sustaining a fall sometime in 2021 in the evening, when R1 attempted to get up unassisted while watching television. Staff indicated they were nearby but were assisting another resident and could not get to R1 prior to the fall. R1 did not sustain any injuries in the fall and therefore, did not require additional medical treatment. No incident reports were submitted to CCL referencing R2 during the time period of the complaint. Staff interviewed did not recall any injury occurring involving R2 during their time working with R2 at the facility. Interview revealed that if any residents are injured or if staff notice any bruising, they care for the injury, make note of the bruising in a log, and inform the Licensee Representatives. One of the Licensee Representatives will then come check on the resident at the facility and determine whether further medical intervention is needed. Record review revealed that neither R1 nor R2 required 1:1 assistance or constant supervision. Based on record review and interview, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “due to lack of care and/or supervision, residents sustained injuries while in care” is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff subjected resident to unusual punishment:”

The complaint alleges that staff were instructed to manually straighten Resident #3 (R3)’s legs and force R3 to walk, although R3 was in pain. Record review revealed that R3 had passed away in August 2018, but the complaint was not received until February 2021. Staff interviewed during the complaint did not work at the facility with R3. However, interview revealed that all residents do exercises at the facility. Staff modeled for the LPA the exercises completed and described them as “basic stretching” of the arms, legs, neck, and body. Staff assist all residents to complete these exercises. Interview revealed that if a resident does not wish to participate, they are allowed to stop participating. Staff stated that sometimes R1 and Resident #4

Report Continued on LIC 9099-C

Regarding the allegation “Staff did not observe change in a resident's condition:”

It was alleged that R4 had an unnoticed change in condition, as evidenced by R4 being unable to feed themselves. LPA reviewed an Incident report, which indicates that R4 “has a long history of UTI. Facility Administrator noticed that [R4] was declining in the past several days.” Incident report further indicates R4’s Primary Care Physician (PCP) ordered a urinalysis; results were negative for UTI. At the request of the Administrator, PCP conducted a home visit and indicated R4 was doing okay. On the morning of 01/15/2021, facility staff noticed R4 to be lethargic, so they contacted the Administrator, R4’s responsible party and called 9-1-1. R4 was transported to the hospital and diagnosed with UTI sepsis and pneumonia. During an initial complaint visit on 02/04/2021, LPA observed R4 sitting at the table with staff members assisting R4 with their meal. Physician’s Report dated 02/07/2021 indicates R4 is on a soft and some puree diet and is unable to feed self, with the comment “reteaching to use left hand, needs staff assistance.” Record review revealed that R4 has a diagnosis of Parkinson’s Disease and Mild Cognitive Impairment. Staff interviews revealed that R4 did require assistance with feeding, brushing teeth, and showers. Staff indicated that last year, R4 was not eating much, so staff would feed a heavy breakfast, as R4 normally ate breakfast well. Staff indicated R4 drank a lot of water throughout the day, even when R4 wasn’t eating much. When R4 wouldn’t eat, the facility staff called the Licensee representatives to check on the resident. Although it is unclear whether R4 had a change in condition, it is documented in the Incident Report that the facility staff did notice a change in R4’s behavior and contacted the resident’s physician to obtain additional medical care. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “staff did not observe change in a resident’s condition” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C

During the course of the investigation, LPA reviewed needs and service plans and physician’s reports for the residents referred to in the complaint. LPA also conducted interviews pertaining to the residents’ needs with the facility staff. Interviews revealed that each resident has unique needs, and their care is coordinated to meet each individual’s needs. Some residents shower independently, and some require assistance, others require incontinence care while others manage their own toileting needs. LPA observed staff assisting R4 with feeding during the initial virtual visit. During a subsequent facility visit, LPA observed facility staff assisting another resident with feeding and another with toileting and escorting. Residents interviewed indicated their needs are met and the care provided is good. All residents observed appeared clean, dressed, and groomed appropriately. Based on interview and observation, at this time there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “staff not assisting residents with ADLs” is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Staff improperly transferred resident”

The complaint alleges that R4 is a 2-person assist, however, Staff #1 (S1) was instructed by other facility staff to transfer R4 alone. During the investigation, R4’s needs and service appraisal was reviewed and indicates R4 “requires 2 people max assistance.” Physician’s report indicates R4 is unable to independently transfer to and from bed. One staff interviewed indicated that R4 is a 2-person assist for transfers, however a second staff indicated that R4 is a 1-person assist often, as R4 is frequently able to assist with their own transfers. R4 would hug the facility staff while the staff assisted R4 in standing up. During the initial virtual complaint visit, LPA observed one facility staff assist R4 get up out of the recliner chair and transfer R4 to their wheelchair using the hugging method described. During the interviews, LPA asked facility staff if S1 was able to independently transfer R4 and staff indicated yes, S1 was able to independently transfer R4, however, they had previously assisted S1 as needed with R4’s transfers. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation “staff improperly transferred resident” is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of the report was provided.