Facility Evaluation Report

On 8/17/22 at 10:34 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced visit to deliver final findings for an incident of suspected abuse at the facility listed above. LPA met with Cindy Baker, Administrator, and Donna Pieprzycki, RN/Nurse Consultant.

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.