complaint·June 19, 2025

Continued from LIC 9099 Allegation “Due to lack of care and/or supervision, resident fell and sustained fractures:” The complaint alleges that Resident #1 (R1) fell while using the restroom, resulting in multiple rib fractures. LPA reviewed R1’s physician’s report dated 11/27/2023, which indicated that R1 has diagnoses which include Mild Cognitive Impairment and gait impairment. R1 was determined to be non-ambulatory at that time. R1’s physician’s report did not indicate that R1 required transfer assistance and R1 was determined to be able to care for their own toileting needs. R1’s service plan dated 01/20/2024 indicated that R1 was participating in the facility’s fall program to reduce the risk of falls. Staff also offered R1 additional spot checks. Interviews and documents reviewed revealed that R1 fell on the following dates: 12/26/2023, 06/08/2024, and 06/11/2024. Staff interviewed stated that after a resident has fallen or is determined to be a fall risk, staff conduct additional documented status checks and staff complete a fall risk assessment. The facility provided incident reports, as well as documentation of status checks, fall risk assessments for all R1’s identified falls. The facility also provided documentation of notification sent to R1’s physician related to recent falls. Reporting party indicated that R1 does have a walker that has been recommended for R1’s safety, however it’s R1’s personal preference to not use their walker. On 06/11/2024, facility staff assisted R1 to the restroom then staff stepped out of the room as R1 requested privacy. R1 attempted to get up on their own and fell. R1 reported pain in their ribcage, facility staff encouraged R1 to go to the Emergency Room, but R1 declined additional medical attention. Later that day, after speaking with their family member, R1 went to the Emergency Room. Medical records reviewed revealed that R1 did not sustain any fractures due to the falls. X-ray results indicated “no displaced rib fractures” and no pelvis or hip fractures. Although R1 did fall while using the restroom, the resident did not require 1:1 supervision at all times and did request privacy. Additionally, medical records indicate R1 did not sustain any fractures as a result of the fall. Therefore, the information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Allegation: “Staff made an inappropriate comment in the presence of a resident:” It was alleged that when staff brought R1’s commode to the restroom, that staff commented on the commode’s odor. During the investigation, staff and residents were interviewed. No staff nor residents Report Continued on LIC 9099-C Continued from LIC 9099-C interviewed have heard any such comments. Residents reported that staff are professional in their interactions with the residents. Staff denied the allegation. Reporting party was unable to provide any specific information to corroborate the allegation and although LPAs attempted to contact R1 multiple times, LPAs were unable to reach R1. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. A copy of today’s report was provided.