complaint·April 17, 2025

On Saturday, March 22, 2025, Resident #1 (R1) had a fall in their bedroom at or approximately 6am verified by R1. As a result of the fall, R1 sustained a small one inch laceration to the right brow bone region per the hospital discharge summary dated March 24, 2025. Three out of the four staff interviewed indicated conducting a fall assessment, taking vitals, and administering first aid to the wounded area immediately. The photograph demonstrates R1 with a band aid applied by the facility while the second photograph shows R1 with steri strips applied by the hospital which was noted on the discharge summary. R1 also confirmed facility staff treating the wound the day of the fall. In an interview with EA, there was not an immediate need to call 9-1-1 based on the assessment and R1 not showing/expressing any signs of pain. EA indicated that R1's representative was immediately notified by telephone following the fall. Based on the review of the call log screen shot, EA placed the call to R1's representative and left a voice message the day of the fall at 6:32am. The outgoing call was for 6 minutes. EA indicated that at 6:48am, the call was returned the same day by R1's representative and discussed R1's condition and vitals for four minutes. EA indicated that R1's representative was asked if they wanted R1 to be taken to the emergency room, even though EA did not believe the injury required immediate medical attention. EA indicated that the representative declined. Due to conflicting information obtained during the investigation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Staff did not seek medical attention for resident is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Administrator Jozef Springer, and a copy of this report including the LIC811 were provided at exit.