Complaint·December 17, 2024

9099C-1.. The complaint relates to resident (R1) who moved to the care home on 9/12/24 and was sent out to the Emergency Room on 9/15/24. Resident's Physician's Report notes (R1) had a diagnosis of: Diabetes Type 2; Chronic Systolic Congestive Heart Failure; Delirium without Dementia and Mild Cognitive Impairment. The report further indicates (R1) was able to follow instructions, communicate needs, was non-ambulatory (due to their physical and mental condition) and was not able to leave the facility unassisted. Allegation: Staff handled resident in a physically inappropriate manner. The complaint alleges that sometime from 09/12/24 -09/14/2024 facility staff (S1) yanked (R1) by their shirt when they tried to go outside for a walk, which caused (R1) to fall on the ground. Staff (S1) stated she worked with (R1) from Thursday thru Saturday after (R1) moved in on Thursday evening, 9/12/24, around 4:00 pm. (S1) stated (R1) was "very rude and disrespectful" to her and other staff, explaining (R1) pulled the gate open and hurt (S1's) toes and punched (S1) and was also verbally abusive. (S1) stated (R1) walked without a walker, would curse, disrobe and throw things, including their diaper on the floor, asserting (R1) "was strong with a big build". (S1) stated she knows how to "maintain professionalism" and she kept quiet when (R1) was yelling and "never slapped (R1) or hit her", stating "I don't do those things". The House Manager stated the Administrator, Leyla, was present when (R1) was pulling at the outside gate and wanted to leave and called 9-1-1 and then (R1's) family, commenting "it was very concerning when (R1) tried to leave since the facility is located on a busy street". The House Manager stated there was no police report taken, (R1) was "happy to move in and didn't seem to have problems" and (R1) was "okay the first two days". The Administrator at the time stated that after the first two days,(R1) was "walking around naked and taking off their diaper", explaining that when (R1) was at the hospital, prior to being admitted to the care home, , she assessed (R1) and "no one told me they had behaviors- (R1) changed quickly- maybe (R1) had a UTI- because the last two days, we couldn't control (R1)". The Administrator asserted (R1) "was the aggressor with (S1)" and "hurt (S1's) foot". (R1's) family member stated she received a phone call from staff just (2) hours after dropping (R1) off on 9/12/24, asking her to pick (R1) up as (R1) tried to leave the facility and broke (S1)'s toe. The family member stated (R1) uses a walker and when (S1) went outside with another client to get some sun, (R1) tried to leave. *cont on 9099C-2... *9099C-2... The family member stated she told staff that (R1) "does not walk without a walker" after staff told her that (R1) wheeled thyself in her wheelchair to the back yard and stood up in their chair to open the gate, and asserted "there was no physical way she could do that". The family member stated she thinks staff, (S1), grabbed (R1) from behind and (R1) fell. The family member stated the Administrator, Leyla stated (R1) "couldn't talk as they had no teeth" but (R1) told the family member they were hit by staff, commenting she honestly thinks (R1) fell, and the rehab says they are "fine". The family member added that Leyla, Administrator, told her several times she/the facility has had complaints about (S1). (S1) is no longer employed at the care home as of 9/30/24. (R1) was not available to be interviewed. (3) current residents indicated on 12/17/24 staff are always respectful to residents. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that a complaint allegation 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. Allegation: Staff yelled at resident . The complaint alleges that facility staff (S1) was yelling at (R1) and slapping their body, causing a bruise on their left arm and (R1) does not want to go back to the home because they feel unsafe. Resident's family member stated that (S1) did not yell while she was visiting the facility but (S1) yelled over the phone, explaining one time, (R1) was yelling, and staff couldn't get her to calm down. The family member explained on Sunday, 9/15/24, Administrator, Leyla, called the Emergency Room at 11:00 pm, and then called her and told her (R1) had a stroke and stated (R1) told the hospital then that staff had "hit them", but there were not any visible marks, commenting when she visited (R1) at the hospital, they were upset and wouldn't show the family member their arms and legs. The family member stated (R1) told her that (S1) hit them (R1), but the family member thinks staff,(S1) grabbed (R1) from behind when (R1) was trying to leave, and they fell. The family member stated when she dropped medications off for (R1), (S1) pointed to the circle table in the common area and told her to "leave them there", commenting (S1) appeared to be "rough". Staff felt (R1) had advanced Dementia with uncontrollable behaviors, which were impossible to manage and was sent to the emergency room for not sleeping for two days. ( S1) stated she knows how to "maintain professionalism" and she kept quiet when (R1) was yelling and "never slapped (R1) or hit her", stating "I don't do those things". *cont on 9099C-3.. *9099C-3.. The administrator indicated the first day (R1) moved in was a Thursday and that night, "(R1)) was refusing to go to bed", so she called 9-1-1 as she observed (R1) to be "dizzy and breathing hard, and showing very erratic behavior and couldn't walk". The administrator explained that 9-1-1 said (R1) "maybe had a UTI". The House Manager stated she met resident, (R1), once after returning to the facility with groceries, and she heard from staff, (S1) that (R1) was "walking around naked and was violent and verbally abusive to (S1)". The family member stated (R1) was “mean to (S1)” and she observed (R1) to have behaviors one time while at a doctor’s appointment, just before being diagnosed with a UTI and high blood sugar. (R1) walked out of the bathroom with a diaper and top on only and no pants and was asked by security to leave. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that a complaint allegation 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. Allegation: Staff did not ensure resident was fed. The allegation states that facility staff were not feeding resident (R1). The Administrator stated (R1) "ate well and ate everything" commenting "we make good food". The family member was asked if the facility was denying (R1) food or meals and commented, "No, (R1) likes everything, but they can't eat it all due to having no teeth- (R1) likes baked potato". (S1) stated (R1) refused vegetables on her dinner plate and would be "cursing during meals". (S1) commented (R1) ate three times a day and "ate all their food except for veggies- (R1) would eat snacks, including pudding and yogurt." LPA interviewed current residents on 12/17/24. All residents indicated they are served (3) meals a day and snacks. LPA observed current food supply in the kitchen- meets 2+day perishable and 7+day non-perishable supply requirement. LPA observed a hot lunch being prepared while at the facility on 12/17/24. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that a complaint allegation 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 9099C-4... 9099C-4... Allegation: Staff did not dispense medication to resident as prescribed . The allegation states staff are not giving (R1) their scheduled medications. Staff (S1) stated (R1) would demand her medications, exclaiming to staff they wanted them "now". (S1) explained that (R1) only refused medications one time, on Thursday evening, 9/12/24, but did take them twice each day on Friday and Saturday. (S1) stated she left (R1's) meds in a cup and waited for (R1) to take them, and when(R1) didn't take them, (S1) placed the medications back in the cabinet. (S1) added that (R1) moved in without any behavioral medications and was told by (R1's) family member on Saturday, 9/14/24, that (R1) had psychiatric medications she forgot to pick up when (R1) moved in. (S1) commented that the family member "never brought these medications over". The administrator stated it is correct that (R1's) psychiatric medications were never brought to the facility, explained that the nurse at at the hospital called her on Monday, 9/16/24 to advise the medications were waiting at the pharmacy. (R1's) family member stated the Administrator, told her (R1) was "not taking their pills" The family member stated she observed (R1) take pills, on Friday, that were on the dining room table, and she was "not sure" if they were (R1's) but (R1) didn't have any adverse reaction. The family member initially indicated that "everything was brought to Sunrise Village" but then said after she picked up (R1's) meds, she got a phone call when she got home that there were (2) more medications- both psychiatric, that weren't picked up, stating, "(R1) may have not gotten their psych meds" but (R1) had not taken them for 2 months. LPA reviewed the Centrally Stored Medication Record for (R1) which documents (8) medications (R1) moved in with but none of them were psychiatric medications. Initial medication list was reviewed that was provided with the physician's report. (3) residents were interviewed on 12/17/24, as each resident state they are receiving medications as ordered . Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that a complaint allegation 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 with Rodica who was authorized to sign today's report. Copy of report provided.