GEORGETOWN TOWNSHIP, Mich. (WOOD) — The woman who was in charge of a Jenison adult foster care home the night a man walked away and died said the home was understaffed and that she was not properly trained.
A state investigator has recommended that the state revoke the license of American House Senior Living Cherrywood in response to the Oct. 14 death of 83-year-old Calvin Powers.
Ghyslaine Mapendo, 23, a medical technician, was the only trained person working that night at the 20-room memory care home, according to the state.
She told Target 8 she had no way of knowing that Powers had walked away from the locked facility and lay outside for more than seven hours in the cold and rain.
“He was my friend, and when it happened I was so shocked, and I … cry,” Mapendo said.
The 23-year-old said she was a med tech for American House Senior Living for six months, including two months at the home in Jenison.
“My job was to give medicine to the residents, not to see them if they go outside, no,” she said.
But that night, according to the state report on the death, she was training two new aides.
“They give me two people that don’t have experience; they was new,” she said. “I was only one med tech, so (it) was too much for me that day.”
“I have to show them how to do this, how to clean, how to change, but nobody stay on the front (near the front door), so we never know maybe somebody could be go outside,” she said. “Nobody would know that.”
She said she was passing out meds when Powers, a hospice patient known for wandering, pulled the fire alarm about 7 p.m. He was one of 14 residents that night.
“I was, ‘Don’t do that. Don’t go outside.’ Because he was like my friend. He would listen to me,” she said.
The state report cited the home for not only being understaffed, but also for not training her how to reset the alarm.
“They teach me that the next day,” she said.
Surveillance video shows Powers walked out the front door not long after pulling the alarm. His body was discovered in the grass after 2 a.m. the next day, not far from his walker.
The state report shows that staff members admitted not checking on his room every two hours as required. The med tech told the state she and the aides were making bed checks at 10 p.m. but didn’t check on Powers because he was considered independent.
The state wrote that Powers’ “protection and safety was not attended to and likely led to his demise.”
His family says the home cost the family $5,700 a month.
“Due to the severity of the violations, disciplinary action against the license is recommended,” the state investigator wrote.
Powers, diagnosed with Parkinson’s disease, reportedly had suffered delusions and hallucinations that “led him to looking for an unknown baby and/or his mother,” according to the report. The home knew he was a risk of walking away, the report shows. He’d been living in another adult foster care home in the same complex when he walked away less than two weeks earlier.
The state also cited the home after the med tech admitted tying a gait belt, the kind used to help move patients, around a resident’s waist and to a chair to keep him from falling. She told the state it was the only way to keep him safe because they were short-staffed.
The med tech said American House fired her shortly after the death.
“That’s not even fair, because I was trying my best to do my job,” she said.
The home is one of 18 adult foster care homes operated by American House in Kent and Ottawa counties. Seven of the 18 have now been cited for understaffing over the last two years.
It also operates a much larger home for the aged, American House Wyoming, which was cited for being understaffed two years ago.
The death was the second in a little more than a year involving a resident who walked away unnoticed from an American House adult foster care home. Jean Bruin, 86, who suffered with late-onset dementia, wandered away from American House Cobblestone Kentwood on June 2, 2022. She drowned in a pond near the side door. The state report said alarms on exit doors were “either inoperable or disengaged.”
The state’s Bureau of Community and Health Systems issued a notice of intent on Nov. 6 to revoke the license of the Jenison home, according to a spokesperson for the Department of Licensing and Regulatory Affairs.
The bureau will decide whether to revoke the license after giving American House a chance to appeal. The home can remain open in the meantime.
American House emailed a statement to Target 8:
“At American House Senior Living Communities, the health and safety of our residents is our number one priority. We are deeply saddened by the passing of one of our residents on October 14, and we are offering our support and condolences to the resident’s loved ones. We respect the state’s advocacy for ensuring the implementation of Adult Foster Care regulations and are working closely with state officials to review their findings to ensure we continue to provide the high-quality care our residents deserve and have come to expect. We remain committed to our mission of providing the thousands of American House residents we care for and have cared for over the past 44 years with high-quality housing and care, and we’ll continue to work with all stakeholders during this ongoing investigation to identify opportunities for improvement moving forward.”
Last year, the state revoked 14 adult foster care licenses.