complaint·April 24, 2025

Page 2 Allegation: Staff refused to accept resident (R1) back to the facility after an emergency (ER) visit. The reporting party (RP) stated that the facility administrator (ED) refused to accept R1 back to the facility due to a bed issue. The RP stated that R1’s semi electric bed which was brought to the facility from R1’s home was broken and unless R1 is provided with a replacement bed, either a hospital bed or another semi electric bed, ED won’t admit R1 back, and that ED said R1 has not eaten in 24 hours and has become agitated because of the bed being broken. ED denied the allegation that she refused to admit R1 back. ED stated the staff reported to her on 7/17/22 that the remote control of R1’s bed was broken and that R1’s daughters (FM1 and FM2) came to the facility on 7/18/22 and R1 was agitated because of the bed being broken and would not eat. R1 can feed self but would not want the staff put pillow to elevate/raise her head and was refusing to eat that day. ED also stated that she told the hospital several times to arrange the rental bed which will take only one hour, and that they can send the bill to the facility and the facility will get paid by the responsible party. ED further stated she told FM1 and FM2 they can rent a hospital bed temporarily, but the daughters were saying the insurance would not cover 100% of the cost. FM1 and FM2 told them to call 9-1-1 so R1 was sent out. R1 may also have UTI because R1 was very agitated that day. R1 was discharged back to the facility on 7/19/ 22. R1 stated not remembering what happened to her bed. LPA observed R1’s bed was working on 7/27/22. LPA tried to reach to FM1 and FM2 to obtain information, but they did not return LPA’s call. S1 and S4 confirmed ED’s statement that the remote control of R1’s bed was broken and that R1 was agitated and refusing to eat. S1 stated R1’s bed was broken on and off and the issue reported to R1’s daughters. S1 also stated that R1 was sent out on 7/18/22 and discharged back on 7/19/22. Hospital After Visit Summary showed R1 was admitted on 7/18/22 for feeding and behavior problems and discharged on 7/19/22. Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated. ....continued on 9099C (page 3) Page 3 Allegation: Staff did not ensure that resident's (R1) bed was in working condition. S1 stated R1's bed has been on and off broken and R1’s daughters were informed and aware. Prior to the last time the bed was broken on 7/17/22, the daughter sent a motor to the facility and the motor of the bed was replaced. The bed was not a hospital bed, but part of the bed can be raised with a remote control. S4 confirmed that the remote control of R1’s bed was broken. During interview on 7/27/22, R1 was not able to provide information about her bed but stated she’s happy. LPA observed R1’s bed was working that day. LPA tried to reach to FM1 and FM2 to obtain information, but they did not return LPA’s call. Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated. Allegation: Staff did not ensure that resident (R1) was adequately fed. S2 stated she fed residents during her shift and if residents refused to eat, she reported to her supervisor and facility nurse who gave her instructions what to do and she followed the instructions. S2 further stated they cannot force feed the residents, and that residents have right to refuse, but she came back and offer food 2 or 3x. She documented if resident still refused. S4 stated the caregivers were feeding R1. S4 also stated that R1 knew that R1 has medications that needed to be taken with food. S4 further stated that she does not remember any incident where caregivers refused and/or didn't feed R1. R1 stated she likes to eat dinner at 5:00 p.m. and dinner is already prepared at that time but was not able to provide information if caregivers refused to give her food. ....continued on 9099C (page 4) Page 4 Based on information gathered and LPA unable to obtain information from FM1 and FM2, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.