Complaint·March 7, 2023

Allegations - Resident sustained severe injuries while in care and staff did not seek medical attention for resident in a timely manner. – Unsubstantiated. According to complainant, R1 had fell during the night on 07/21/2022. On 07/22/2022 at 10 AM, R1 was observed on the floor with blood on the face. R1 had hit their head when R1 fell at night but now hand is swollen with bruising on wrist. Health Care Director, Kashmir Dutt, was called to evaluate R1 and was told R1 would be alright. R1 went to the hospital three (3) days later for hand injury. Complainant stated R1 had a fracture. The Department received an incident report from the facility for review. Incident report indicated on 07/24/2022 at approximately 4:15 AM, caregiver was conducting rounds and discovered R1 on the floor in the restroom. Caregiver observed R1 with a bruise above the right eye. R1 was assessed and 911 was called for transport to the hospital for further evaluation. According to medical discharge documents, R1 was not diagnosed with a fracture. On 04/28/2022, R1 was placed on hospice. Allegation - Staff are mismanaging resident’s medication. – Unsubstantiated. According to complainant, MAR was not accurate, cups of medication are sitting and haven’t been provided to R2 on 07/18/2022 and 07/27/2022. The Department requested and received R2’s MAR for review for the month of July and August of 2022. R2’s MAR for the month of July 2022 indicated, R2 had taken medications on 07/18/2022. There were two (2) medications that needed refills. According to July’s MAR, R2 has consistently refused medications on 07/27/2022. Allegation - Staff are forcing residents to take medication. – Unsubstantiated. According to complainant, R2 had refused medication and the Wellness Department are telling staff to hide R2’s medication in coffee or oatmeal. The Department interviewed a total of five (5) facility staff. All facility staff denied the accusation of forcing R2 to take medication. Interview statement received from S2 indicated, R2 often refuses medication. S2 stated the facility’s medication policy is once a resident refuses medication staff would try three (3) more times. If residents continues to refuse staff would document down that resident refused medication. Interview statement received from S3 indicated, S3 has never observed staff forcing resident to take medication and that every resident has the rights to refuse. S3 stated staff is not allowed to disguise medication for residents to take. Interview statement received from S4 indicated, S4 has not observed staff forcing residents to take medication and will follow doctor’s orders. S4 stated if doctor’s orders indicate medication can be mixed with apple sauce, then facility will follow it. Allegation - Staff did not prevent a resident from taking another residents medication. – Unsubstantiated. On 08/17/2022, LPA Keosavang emailed and called complainant via telephone to conduct pre-investigation and gather additional information. LPA was unable to get ahold of complainant. Complainant’s contact number provided during the initial intake of complaint was out of service. According to the summary details of the allegation and description of the incident received during the initial intake of complaint, complainant observed R3 in dining room with a pill in hand and gave the pill to R4 to take. LPA was unable to determine the identity of R3 and R4. The Department interviewed and received statements from a total of five (5) facility staff. Interview statements from all five (5) staff were consistent and indicated they have not observed a resident giving medication to another resident in care. Interview statement received from S3 indicated, staff administer medications in the office individually or in resident’s room. Medication is never given in common areas. S4 state in the memory care unit, medication is given to residents in a conference room or resident’s room for privacy. Due to the information above, CCL finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Executive Director, copy of report was provided via email. Appeal rights were printed and given with the report.