complaint·June 15, 2023

According to the Administrator, the visitor came on 1/1/23 with an “intimidating” friend who was over 6 feet tall and the Administrator stated they tried to force their way in to the facility, and were yelling and using racist remarks towards the Administrator and staff. Administrator stated they did not feel safe or comfortable letting them in. Administrator was also concerned that the visitor, who was not R1’s POA, may try to take R1 out of the facility again or may abuse R1, as had been concluded by APS in the past. LPA advised the Administrator that they should have called 911 if they felt threatened, and the only way to restrict visitation is to get a restraining order. Administrator filed for a restraining order against this visitor, and the temporary restraining order was granted. Based on the information obtained, the allegation is deemed Substantiated at this time. A technical Violation was issued. Exit interview conducted, copy of report and appeal rights were printed and emailed. RP stated they had a video of R1 begging and pleading to leave with RP and R1 grabbing onto the staircase banister due to staff roughly taking R1 back to their room. LPA reviewed facility incident report that states on 10/5/22 R1 became agitated when a visitor came to the facility asking R1 for money and then demanding to take R1 out of the facility. 911 was called and R1 went to the ER to get checked out, the facility also contacted APS. The resident was discharged with a UTI and put on antibiotics. LPA interviewed Ombudsman who stated they visit the facility once a month and routinely check for bruises and signs of abuse. Ombudsman stated they have not seen any suspicious bruises on any residents. LPA interviewed APS, who indicated they had received reports of abuse between R1 and their visitor, and did not refer the case to CCL because there was no indication of facility abuse towards R1. LPA reviewed hospice notes from R1 which did not indicate any bruising or concerns about rough handling. LPA Chavez observed R1 on 4/3/23 but could not observe bruises on R1 because R1 was covered in a blanket and sleeping. LPA Olson observed the video footage from reporting party and observed a few bruises on R1’s hand, on the very tops of R1’s hand. There were no bruises visible on the arms or wrists. LPA interviewed Administrator, who indicated R1 had bruises on their hand after the visitor visited R1. However, Administrator noted the bruises stopped after the visitor stopped visiting R1. R1’s physician’s report dated 9/2/22 indicates they have diagnoses of dementia, agitation, TIA, anxiety, and incontinence. LPA reviewed additional portions of the video filmed by the visitor. The video shows the visitor asking R1 leading questions and guiding them to a specific answer. The visitor gets R1 to indicate the staff are “mean” and the bruises are from the staff. The visitor tells R1 that their POA is “killing” them, and that the visitor could not obtain money because of the POA. LPA interviewed the other residents at the facility. Residents indicated the staff were nice, met their needs, and did not hurt them or handle them in a rough manner. LPA also did not observe any bruises on residents hands, arms or wrists. Based on the information obtained, there is insufficient evidence to prove that staff roughly handled R1 leading to bruising. Therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report emailed and printed.