Complaint·July 15, 2025

It is being alleged that a resident sustained an acute minimally displaced LI fracture while in care. On 01/22/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Per 1 of 3 staff interviewed, on 12/01/24 resident reported sliding off bed, resident was assessed, resident denied any pain or injury, resident refused to go to the hospital, and resident was placed on “watch alert.” On 01/22/25 The Department conducted interviews with R2-R4 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. The Department conducted a review of medical records for R1, medical records revealed that R1 has a history of Osteopenia, subsequent L1 fracture, and mild degeneration (grade 2) to both the right and left hip, which has a higher risk of subsequent fractures. The Department conducted a review of R1’s file, per preplacement assessment dated 08/17/23 R1 is independent in bed mobility and transfer. Allegation: Staff did not seek medical attention for resident in care in a timely manner. It is being alleged that resident did not have a medical evaluation done after fall. On 01/22/25 The Department conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Per 1 of 3 staff interviewed, on 12/01/24 resident reported sliding off bed, resident was assessed, resident denied any pain or injury, resident refused to go to the hospital, and resident was placed on “watch alert.” On 01/22/25 The Department conducted interviews with R2-R4 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. The Department was unable to conduct an interview with Resident #1 (R1) due to communication barrios. The Department conducted a review of R1’s file, per preplacement assessment dated 08/17/23 R1 is independent in bed mobility and transfer. Per review of communication log dated 12/01/24-12/19/24 R1 was being checked on by staff, per communication log there were no complaints of pain or discomfort, and resident refused to go to the hospital. The Department confirmed that an unusual incident report was sent to CCLD regarding R1’s fall on 12/01/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.