Complaint·March 20, 2024

Regarding the allegation: Resident sustained an unexplained fracture while in care. It is being alleged that resident had facial edema, slight bruising to left eye and has a nasal fracture. On 12/13/23, IB Investigator, John Canto requested medical records from Norwalk Community Hospital . Resident #1 (R1) was transported there on 12/08/23 for hypertension and concerns with areas of the face, eyes, nose, and mouth. R1’s nasal deviation was noted as chronic. Upon admission to the hospital, R1 also had an altered mental status, hypertension, seizure disorder and dementia. On 12/11/23, it was noted on the CT Head Scan (without IV contrast) that there was no skull fracture; therefore, paranasal sinuses are normal as shown which confirms that R1 did not have any skull fractures. On 12/13/23, it was noted that R1 was sent to the emergency room due to edema of bilateral lower extremities. R1 had a history of bumping their head on the toilet and scooting on their knees. On 01/16/24, IB Investigator attempted to interview R1’s social worker but was unable to obtain an interview. On 02/06/24, IB Investigator Canto interviewed three (3) staff and one (1) out of three (3) residents. Two (2) residents were unable to participate due to their cognitive abilities. The three (3) staff were able to confirm that R1 was housed in the memory care unit, would scoot on their knees, would argue, steal from residents, and would overeat. The medical records from 12/12/23 for R1, shows no facial swelling and/or rashes and was normal. The nose also shows no mass or deformity. Based on the observation of the IB Investigator, interviews conducted, and record review, the allegation is UNSUBSTANTIATED. Regarding the allegation : Resident became malnourished while in care . It is being alleged that the resident is very confused, malnourished, and thin. LPA was able to obtain the Physician’s report of 2023 which shows Resident #1 (R1) weighed 121lbs, the physician’s report of 2020 showed a weight of 115lbs which showed that R1 gained weight. In addition, the weight at the time of hospital admittance on 12/08/23 shows that R1 weight at 80 kilograms (176 lbs.). LPA interviewed seven (7) out of eight (8) that confirmed R1 would eat their own food and ask others for their food or sometimes even steal other resident’s food. LPA interviewed seven (7) residents out of eight (8) that also confirmed that they can receive extra food from the kitchen if they are still hungry. LPA was also able to interview four (4) out of four (4) staff that confirmed that R1 would steal food and request extra food from staff and other residents. Therefore, based on the LPA's interviews, observations, and record review, the above allegation(s) UNSUBSTANTIATED. LIC 9099C-continued Regarding the allegation: Facility retains a resident with a higher level of care needs . It is being alleged that the resident needs a higher level of care due to their severe dementia. The facility Administrator was able to provide the LPA with the referral name and number to the Department of Health Services (DHS) in which the facility Administrator has made several attempts to help Resident #1 (R1) get a higher level of care. The facility Administrator confirmed that R1’s mental status has deteriorated since R1 has arrived at the facility. LPA was able to interview the DHS-Lisa Speights that oversees R1’s referral from the facility. DHS was able to confirm that the facility has made several attempts to try to get R1 more care and help but DHS stated it is not that easy. DHS stated there is several steps to this process and it will still take a while to get R1 to be moved from the above facility. LPA was able to interview four (4) staff that were able to state how each resident’s level of care differentiates between each other and how they provide that level of care. Four (4) out of four (4) staff also confirmed that R1’s level of care had deteriorated. LPA was also able to interview seven (7) out of eight (8) residents regarding their level of care. Seven (7) out of eight (8) residents confirmed that their level of care needs is met by the staff, case managers and social workers. Therefore, based on the LPA's interviews and record review the above allegation(s) is UNSUBSTANTIATED. An exit interview was conducted, no citations were issued for the above allegation(s), and a copy of this report was given to the Administrator.