complaint·April 15, 2025

The allegation of “Facility staff did not report incidents to resident's responsible person” alleges that the facility did not notify the responsible party of Resident #1 (R1) of falls that R1 experienced while in the care of the facility. During interviews with residents of the facility Resident #2 (R2) stated that they experienced a fall at the facility about one month ago. Additionally, R2 stated that they suffered an incident where a table that was leaned up against a wall of the facility slipped and hit their ankle. LPA interviewed Staff #1 (S1) who remembered both of the incidents involving R2. S1 also recalled R1 experiencing a fall while at the facility. S1 stated that R1 attempted to walk without staff assistance and fell forward hitting their face on the ground. S1 stated that R1 experienced a cut on their upper lip and a scratch on their neck. S1 stated that for both R1’s and R2’s falls they notified the Administrator of the incidents. LPA reviewed the facility’s E-Folder for incident reports. LPA observed the incident folder to be empty and confirmed that no incident reports were pending review in their folder. LPA informed the Designee who stated that they were unaware of any falls occurring at the facility. LPA interviewed the Administrator who confirmed that they were aware of three (3) falls that occurred at the facility. LPA asked the Administrator if incident reports were submitted for the falls and the Administrator confirmed that they were not. The Administrator confirmed that they would submit reports for all resident incidents in the future. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Facility staff did not report incidents to resident's responsible person.” Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (refer to LIC 9099D). This report was read to the Administrator via telephone call. A copy of the report was printed, appeal rights were provided, and exit interview was conducted. The allegation of “Facility staff did not assist resident with medical appointments” alleges that the facility did not assist R1 with doctor’s appointments and testing. Interviews with current residents of the facility did not reveal any concerns with residents receiving medical care or assistance in arranging appointments. Interviews with S1 revealed that they were never made aware of R1 requiring assistance in arranging or transport to medical appointments or testing. During the interview with the Designee they stated that R1 was a resident of the facility for such a short time and denied the responsible party of R1 ever making the facility aware of needed testing’s or appointments. The Designee stated that appointments for residents are conducted with physicians either in person or over Facetime. Additionally, the Designee revealed that the facility has contact with a mobile doctor that can evaluate residents if needed. LPA interviewed the Administrator who denied R1's representatives ever informing them of a doctor's appointment or test for R1. The Administrator confirmed that R1 resided at the facility from 03/24/2025-04/09/2025. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Facility staff did not assist resident with medical appointments.” Therefore, the allegation is deemed Unsubstantiated at this time. This report was read to the Administrator via telephone call. A copy of the report was printed, and exit interview was conducted.