complaint·September 26, 2024

Interviews with staff revealed R1 was leaving the facility on an outing, facility’s driver assisted R1 standing near R1 and providing hand for support. R1 place her hand on driver and used her left hand on the van’s handle to pull self-up. As R1 was lifting self-up to get into the van, R1 cried out in pain and stated to have “pop my knee”. Staff called emergency services for R1 who arrived right away and was taken to the hospital by paramedics. Documents reviewed revealed, per physician’s report dated 3/21/24, R1 is ambulatory and does not have any physical impairments. Incident report dated 8/6/24 notes R1 was going in an outing and was “stepping into the community bus assisted by facility’s driver. Upon R1 stepping into the bus, R1 stated to have heard a snap in the knee and was unable to bear weight”. A medication technician assessed R1 and 911 was called to send R1 to the hospital. Per preplacement appraisal information dated 3/29/24 R1 had a “prior broken left femur”, hip and knee. Resident Assessment dated 3/20/24 notes R1 is “independent, self care”. Although R1 may have sustained a fracture, the fracture was not due to hazardous or the facility not being safe. 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 . Regarding allegation: Staff did not prevent the facility from being hazardous resulting in residents sustaining injuries. It is alleged the facility is not safe and they are having "things" in places where they shouldn't be causing residents to fall many times and have gotten injured. Interviews with residents revealed they have not observed hazardous materials or construction materials left in hallways or common areas. Interviews conducted with staff revealed there has been some remodeling done at the facility. However, the tools and materials are kept inside the rooms being remodel and not in common areas or corridors. During the tour of the facility LPA observed the remodel rooms. No hazardous materials or tools were observed in the hallways or common areas. Incident reports submitted within the last month to the department note falls due to other reasons. 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 . Regarding allegation: Staff did not prevent facility from being in disrepair. It is alleged shower stopped working and the A/C unit also stopped working. Interviews conducted with residents revealed shower and A/C has been in working condition and had no concerns. (CONTINUED ON LIC 9099C) Interviews with staff revealed facility’s A/C has been in working condition and no reports of clogged showers had been made. During facility tour a total of 12 resident rooms were observed and each shower/bathroom was in working condition. Temperature in each room was felt comfortable and A/C was working. 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. Regarding allegation: Staff did not follow physician’s order. It is alleged resident did not receive physical therapy for eight weeks due to facility lying agency about whereabouts of resident. Interviews with residents revealed residents are assisted as needed with all their needs. Interview with administrator revealed R1 was not receiving physical therapy or had orders for physical therapy. Documents reviewed revealed Skill Nursing order summary report dated 1/31/24 notes R1 was to received physical therapy, “one time only” until 2/25/24. No other physician orders were observed in R1’s file pertaining most recent physician’s order for physical therapy. Resident Assessment dated 3/20/24 notes R1 is independent to coordinate own healthcare and home care appointments. 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. Regarding allegation: Staff did not prevent resident’s sleep from being interfered. It is alleged resident’s roommate snored loudly and resident could never sleep. Interviews conducted with residents revealed staff responds to residents’ concerns when necessary and have not experience issues with roommates. Interview with administrator revealed, R1 reported the situation. R1’s roommate was moved from room due to residents not getting alone. R1’s roommate was interview and was not able to recall any incidents with roommates. Although the situation may have happened there is not enough evidence to say that the facility did not take action in assisting R1 after reporting R1’s concerns. 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 was conducted with Stephanie Funderburg and a copy of this report was provided.