complaint·April 3, 2023

Allegation: Questionable death Based on records review, On May 18, 2022, R1 was sent to the hospital due to leg pain, R1 was transferred then to a post-acute facility. Records review revealed that on 7/25/2022 R1 passed away with caused of death of vascular dementia. Allegation: Lack of supervision resulting resident sustained unexplained fractured leg while in care On August 16, 2022, department reviewed hospital medical records and records from the ambulance services (American Medical Response). On October 13, 2022, department conducted staff and resident interviews; licensee was interviewed via phone on January 17, 2023. Based on interviews and record review, on May 18, 2022, at around 05:30AM Resident (R1) complaint of leg pain to the night staff but staff said there was no pattern in the way R1 was acting that prompted an emergency response. Staff (S1) stated R1 was normal because by 9AM, she changed her diaper without any issues or complaints. At around 01:42PM, R1 complaint of pain so staff called 9-1-1. Based on documents review, paramedics arrived and found R1 on supine position with no signs of distress. Medical records revealed that R1 was diagnosed of hip fracture with notes of unwitnessed fall, however it was not indicated the cause of injury and only noting that R1 had hip replacement surgery on 2012. R1’s Appraisal/Needs and Service Plan dated June 6, 2021, does not identify fall risk as an issue, R1 was non-ambulatory and wheelchair bound. Allegation: Facility serves low quality food to residents Based on interview and records review, facility has variety of food. LPA conducted interview with four residents (R2, R3, R4, & R7) in care, based on interview, and the residents are satisfied with the food that was being served, Allegation: Facility does not provide planned activities for residents Based on LPA’s observation and residents’ interview. Facility has a planned activities. During LPA’s visits, it was observed that staff are conducting different activities with the residents in care, at least 5-6 residents were observed to be attending the activities. Resident’s interview revealed that there are activities at the facility, however, sometimes residents want to join sometimes resident prefer to watch TV or stay in their rooms. Allegation: Staff did not provide sufficient care for residents needs Based on residents’ interview, facility is providing sufficient care for the residents. Residents stated that the staff are taking care of them and providing the care that they need. Allegation: Resident wheelchair is in disrepair Based on LPA’s observation on residents that are using wheelchairs. The wheelchairs was clean, functional and in good condition. Based on the investigation, above allegations are deemed unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and copy of this report provided.