complaint·July 31, 2025

9099C-1... The Resident Appraisal notes (R1) needs assistance with getting in/out of wheelchair, in transferring in/out of bed and turning in bed/chair, all Activities of Daily Living (ADL’s), has a soft diet. Allegation: Staff are not providing timely care during the nighttime hours. The allegation states that staff are not awake during the night and only provide emergency care. (R1) described a time to LPA when (R1) called for assistance at 4:00 am and staff, "(S3) finally came down" to assist, explaining (R1) had "secretions and needed help sitting up and asked for Mucinex". (R1) stated (R1) waited for an hour. Facility notes from 4/22/25 state “(R1) called for help at 5:00 am to request Mucinex to help her control her mucous and cough: (S3), our caregiver, responded to their call and gave them Mucinex per PRN order. In an e-mail sent to LPA on 5/7/25, (S1) stated the “We can’t verify when (R1) started ringing the alarms, but staff (S3), one of our caregivers, heard the sound at 5:00 am and gave (R1) Mucinex”. (R1’s) family member stated staff she believes staff "wear headphones at night so can't hear the residents" if they call for assistance. All (4) family members for other residents conveyed that staff is only available for emergencies at night. One staff stated to LPA that she and other staff "just for emergencies, we are available at night", and added "once in a blue moon, a resident will push the button" and confirmed (R1) pushed the button before. (S3) stated "if I hear the button, I get up; if (S4) hears it, she gets up". This staff indicated that nighttime incontinent care is not provided, stating "No, it's not provided- they are not checked every two to three hours for a soiled diaper- there is no one in that condition". Review of (5) other residents’ care plan, who were residing in the care home at the time the complaint was received, show that (4) of (5) residents required incontinent checks and/or repositioning. On 5/6/2025, when LPA was opening the complaint, (S1) and (S2) agreed to change their NOC staff coverage to "on-call" and stated incontinent checks can be done at 9:00 pm, midnight and 6:00 am Based on information obtained during the investigation, the Department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met Per Title 22, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided. 9099A-C-1 ..The eviction letter goes on to state that (R1) had care need/s not previously identified and cites (6) supporting points, including, - the facility was not provided with the most updated care plan (dated 2/12/2025) from an outside provider, until after (R1) moved in, on the following day, April 7, 2025, and was provided a care plan (dated 8/12/2024) just prior to move-in . The updated care plan notes (R1) was sent to the ER one time due to increased mucous and decreased lung function, and that (R1) showed the assessing nurse their hands were “flaccid”. Another reason listed in the letter is that (R1) did not disclose all emergency visits when asked at the Pre-Appraisal assessment. Another reason listed is (R1) having a choking episode on 4/21/25 and the facility’s concern this type of episode could happen again, where night staff are “on-call” only. LPA reviewed an e-mail from Administrator on April 28, 2025, to advise the department they “have told the hospital's discharge manager that we can accept (R1) back with a hospital bed and Hoyer lift device, and we are waiting to hear back from the hospital” and a subsequent email to the Department that the hospital hadn’t contacted the facility with any updates as of April 30, 2025. LPA attempted to contact hospital personnel that discussed the conditions of (R1) returning to the care home but was unable to. The department reviewed the 30-day eviction letter and determined it to be a lawful notice, based on containing the required elements as stated Regulation 87224/Eviction . The department does not grant approval for an eviction, in and of itself but only determines if the notice issued is lawful, based on the reasons listed in the above regulation. The letter was reviewed by the Department and determined to contain all the required elements per regulation. A subsequent email was sent from the Administrator to (R1’s) family member on April 29, 2025 where the Administrator reiterates that they “regret they can no longer meet (R1’s) health care needs” due to a choking episode and concerns for (R’1s) respiratory issues; however “we decided to accept (R1) back to our care facility, but we gave (R1) a 30-day notice to find an appropriate care facility”. The family member responds back that the 30-day eviction will not be appealed and discusses moving (R1’s) belongings out by May 13, 2025. LPA discovered that (R1) had moved to a skilled nursing facility following hospital discharge on/around April 30, 2025. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED -A finding that the complaint is Unsubstantiated means 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. *cont on 9099A-C-2... 9099A-C-2.. Allegation: Staff refused to transfer a resident in care. The allegation states that staff did not want to transfer (R1) from their wheelchair to their portable toilet and told (R1) to urinate in their pad, which caused the urine to leak through the resident's clothing and onto their wheelchair. Resident notes document that on 4/7/25, (R1) was upset due to waiting for (2) caregivers to assist with transferring in the morning, so (S2) discussed the doctor approving a lifting device to assist staff. Notes made on 4/9/25 document that it took a long time to assist (R1) out of bed into the wheelchair and on 4/16/25 (S2) discussed with (R1) about getting a different kind of lifting device that the primary health care plan may not provide. The notes state that the discussion occurred due to staff needing to assist (R1) with toileting 4-5 times daily, and staff have been lifting (R1) approximately 8-10 times daily, and complaining of back pain from listing (R1). Notes on 4/17/25 indicate that (S2) told (R1) that the facility would purchase a transport-assisting device and would use it to assist (R1). The notes further document that (S2) showed the video of the device to (R1) to show how it would work and (R1) agreed to use the device as (R1) thought it would work. Charting notes entered on 4/20/25 indicate that “(S2) trained caregivers to use the slide transfer board safely between the bed, wheelchair and commode” by watching a training video and practicing transferring each other” Notes state (S2), who is trained medical professional, “placed a gait belt around (R1’s) torso” before attempting to transfer her but (R1) refused and stated “I’m scared and I have a right to be scared”. (R1) stated (S2) became upset (R1) didn’t want to attempt the transfer with the board and “crossed their arms”. One staff stated (R1) didn't like the board and didn't want us to use the hoyer lift". This same staff explained "(R1) never peed all over stuff and during the day she would call". (S2) Jina stated (R1) agreed to wear Depends (incontinent briefs) in case (R1) couldn't hold their bladder and one time the Depends leaked. Staff washed the wheelchair cushion the same day right away. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED -A finding that the complaint is Unsubstantiated means 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. *cont on 9099A-C-3.. 9099A-C-3.. Allegation: Staff did not follow resident's special diet. The allegation states (R1) was "supposed to have soft food but staff would serve (R1) what everyone else was getting". An example was provided on the morning of April 22, 2025 before (R1) was sent to the hospital, staff was supposed to give (R1) a protein shake but it was given to another resident, so staff gave (R1) a pancake (S2) stated the facility has a menu but they can "adjust dishes based on a resident's preference". (S2) stated there was no discharge note from the doctor and (R1) had protein shakes. (S2) added "(R1) should have been okay with a pancake as it would have been chopped", commenting (R1) “never complained about the food". (S2) explained (R1) "needed a high protein diet" and she got them a plastic fork to use when eating meals, adding that (R1) didn't eat a lot of breakfast but ate lunch and dinner more. (S2) stated (R1’s) last day was Tuesday, April 22, 2025 and they were coughing with mucus at 5:00 am. (S2) stated she was there and "(R1)didn't eat anything for breakfast- sometimes (R1) would just drink coffee and water". One staff who worked on the morning of 4/22/25 could not recall if (R1’s) protein drink was switched with a pancake and commented, "all residents eat the same food except for those on hospice", and "(R1) would buy food on line and have it delivered". A second staff confirmed (R1) had a "special diet" and normally would eat "soft foods, creme of wheat (LPA observed in (R1’s) room) and scrambled eggs, mashed potatoes, Salisbury steak, meat loaf” and would also drink protein drinks. (R1’s) family member stated she was not aware of (R1’s) protein drink being switched for a pancake on the morning of 4/22/25 but (R1) has a "specialized diet that is pureed" and commented the facility would give her pudding cups but is not sure if they were giving her shakes. Four (4) other family members were interviewed and had no concerns about the facility not following a particular diet. One family member stated "mom has to be on soft drinks, so I bring her Ensure drinks. Since she is on hospice, she will eat pudding, yogurt and ice creams". Another family member stated the facility was "restricting the rice" as they felt she was eating too much of it for being diabetic and has offered Tofu instead of beef, as mom requested. Two (2) more family members stated their loved one has no special diet at this time and can eat anything. Based on information obtained, LPA finds this allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means 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. Copy of report provided. 9099A-C-4.. Allegation: Staff forced a resident to go to bed. The allegation states staff were forcing (R1) to be in bed at 7:30 PM. (R1) stated to LPA on 4/24/25 that when (R1) first moved in on 4/6/2025, ”staff started getting her ready for bed at 6:30 pm and brush (R1) teeth, etc and told (R1) she has to be in bed by 7:30 pm”. (R1) added that (S1) told her "you're not working with the girls" when they try and help (R1), and (S1) crossed their arms while speaking to (R1). Charting notes provided to the Department document that (R1) moved in on 4/6/25, “two caregivers assisted (R1) in getting ready for bed and it took 1 hour 25 minutes to complete the bedtime routine per (R1’s) requests” due to (R1’s) particular ways staff has to assist (R1). Notes document that on 4/7/25, (R1) was upset due to waiting for (2) caregivers to assist with transferring in the morning, so (S2) discussed the doctor approving a lifting device to assist staff. Notes from the evening on 4/7/25, indicate the “bedtime routine took 45 minutes” and included staff assisting with multiple ADL’s. A family member of another resident stated, "I know mom has mentioned going to bed early but she stays up and watches tv all night- she is a night owl". Another family member stated “Mom can be in her room, awake and watching television, after 7:30 pm when staff go to sleep”. A family member for a third resident stated "Mom is not forced to- she wants to go to sleep at that time", explaining there are "no restrictions" and bedtime is determined based on the residents in care. All staff interviews confirmed that staff work from 7:00 am- 7:30 pm and are “on-call” during the nighttime only, and all family members interviewed confirmed the night staff is “on-call” only when residents request emergency assistance. (S2) stated the last staff work until 9:00 pm to administer the last medication. (S1) stated to LPA that (R1) created a hostile living environment for staff shortly after moving in, and Notes entered on 4/8/25. (R1’s) family member stated "mom told me a couple of times she was told to get in bed by a specific time". (R1) stated that she was told one time by (S1) that "if she didn't go to bed by 7:30 pm, she would have to sleep in her chair" and stated she did sleep in her chair one time. Resident notes entered on 4/20/25 (evening) state that (R1) “insisted on staying in the wheelchair all night, refusing to go to bed” and that when caregivers offered to assist (R1) to lie down in bed later, (R1) said they were “okay and wanted to stay in their wheelchair”. *cont on 9099AC-5.. 9099AC-5- (S2) stated this was the same evening staff tried to assist (R1) with using the transfer board, and (R1) refused to try due to being scared. (S1) stated (R1) was never told they had to sleep in the chair if (R1) doesn't go to bed by 7:30 pm. (S1) watched (R1) overnight to ensure their safety the one time (R1) stayed in their chair. One care staff stated "at 7:30 pm- (R1) is changed by this time", explaining "it took some time to finish her routine- we started at 6:30 pm- she (R1) would lay in bed and watch tv usually or be on the phone or would watch tv". A second care staff also stated on 5/6/25 that they start getting residents ready for bed at 6:30 pm, explaining how she helps (2) residents get ready, the second staff helps (2) more, and (2) additional residents, are "independent". This staff added "we never told her (R1) she had to go to bed at 7:30 pm" and (R1) can have time to watch television or read before going to sleep but was "unsure" what time (R1) fell asleep. Based on information obtained during the investigation, the Department finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means 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. Copy of report provided.