complaint·June 26, 2023

Additionally, the residents on the 2 nd floor had the option of dinning in their rooms if they wanted too. Later that same day, interviews with various residents starting at 11:25 a.m. confirmed that the elevator was not working for a few hours but by the end of the day, the elevator was fixed. That same day, starting at 11:45 a.m., LPA Ascencio conducted a facility tour, which included the elevator. LPA Ascencio observed the elevator working properly at the time of visit. Based on evidence gathered throughout the investigation, the allegation of elevator in disrepair is deemed unsubstantiated at this time. Lastly, regarding the allegation of resident was injured while in care. On 06/26/2023, interview with Resident #1 (R1) starting at 12:12 p.m. revealed that sometime in September of 2021, R1 was walking up the stair and fell. R1 stated the elevator was not working at the time and used the stairs to get to their room. R1 added that they felt pain in their abdomen and groin area. R1 stated they were not seen by a doctor and that Administrator Melissa Christopher observed the incident and assisted R1. That same day, a file review was performed for R1 at 12:40 p.m., revealing an incident report dated 02/21/2022. The narrative of R1’s incident reports indicates that R1 walked to the top of the stairs and R1 fell/slid at the top of the stairs. Former Administrator Christopher indicated in the incident report that they observed the fall, asked if R1 was ok and if R1 hit their head. R1’s response was that they were ok and did not need any medical attention. Administrator Christopher took R1 to their room in a wheelchair. Additionally, Administrator Christopher added that they checked on R1 a few days later and R1 stated they were feeling ‘OK’ and they did not need any medical attention. Further file review revealed a discharge summary from the skilled nursing facility on 09/08/2021 indicating that R1 is not a fall risk and had genital complications, a Narrative Charting note, dated 10/11/2021, revealed that R1 requested and was transported to the hospital due to discomfort in genital area, and R1’s Primary Physician note indicating that on 10/21/2021, R1 was experiencing genital pain and abdominal pain due to the genital pain which also includes abnormalities in gait, and muscle weakness and mobility. Additionally, a hospital discharge summary was observed, dated on 02/17/2022, indicating that the reasons for visit was due to a headache and complications of the genital area. No other documentation regarding pain or discomfort was observed. Continued on LIC 9099 - C Page 2 Although the date on the incident report differs from what R1 stated, documentation revealed that there was an incident regarding R1 having a fall while walking up the stairs. The incident report was written by Former Administrator Christopher, who indicated in the report, that they observed R1 falling, assisted R1 to their feet and offered medical attention via paramedics. In the incident reports, Administrator Christopher indicated on two (2) separate occasion that R1 refused medical attention and did not need medical attention. Moreover, a file review revealed that R1 sought medication attention on various occasion during any discomfort or pain and that facility staff assisted in obtain that medical attention by calling the paramedics or taking R1 to their primary doctors. Thus, based on evidence gathered, there is not enough evidence to support the allegation of resident was injured while in care. Therefore, the allegation is unsubstantiated at this time. Exit interview conducted and a copy of the report was issued to Staff Ulka Sawghavi. Page 3