Complaint Investigation Report

According to the RP, it was reported that on 06/06 or 06/07 a staff member body slammed a resident onto their bed because they did not know how to put down the grab bars. The alleged resident is on hospice and is unable to communicate. LPA Valerio interviewed the resident's roommate, Resident 5 (R5). However, R5 was unable to provide information related to the allegation. According to an interview with Staff 2 (S2), staff appear to be gentle with the resident. LPA Valerio reviewed the staff schedule for June 2024. LPA did not observe a staff member name that matched the name provided by the RP.

LPA Valerio interviewed six (6) residents. R1 stated staff do not yell at us, they are nice people. R2 did not report any staff yelling at R2. R3 reported that staff are okay and they do not yell at R6 or anyone. R4 had nothing to complain about. R5 was unable to convey if staff yell or do not yell at residents. R6 reported that staff do no yell at R6. Based on interviews with three staff members (S1, S2, and S3), all staff reported that they do not raise their voice or yell at any of the residents.

Staff left resident in soiled diapers for an extended period of time / Staff did not ensure the facility was free from odors

According to the RP, the facility smells like ammonia due to the residents being soaked for hours from the day shift. LPA attempted to gather additional information from the RP; however, RP told LPA to go to the facility and observe it herself. LPA Valerio observed the facility on 07/02/24 and 08/08/24. During both visits, LPA Valerio did not observe any odors resulting from incontinence. LPA Valerio interviewed residents. R1 reported that staff do their rounds about 30 to 49 minutes for each resident. When R1 asks for help, R1 receives help right away. R1 reported that R1 only needs to be checked every couple of hours. R3 reported that staff are supposed to change R3's diaper; however, R3 prefers to do it themselves because they can. R5 was unable to convey if staff assist R5 with ADLs; however, LPA did not observe any signs of soiled clothing or odors. According to an interview with S1, S1 reported S1 checks on them about every hour because R1 does not want them to get a rash. According to an interview with S3, S3 reported that a noc shift staff was fired because she was caught sleeping. The staff member was an employee for a few weeks. S3 came to the facility to check on the staff. When S3 arrived, the staff was observed sleeping and did not notice S3 come in. After S3 was fired, the staff started to blame other staff for tasks that she failed to complete.