complaint·April 29, 2026

It was alleged that on April 24, 2026, R1 had an unwitnessed fall around 1:00AM and did not receive medical attention until 9:30AM when they arrived at an emergency room and were noted to have asymmetric pupils. LPA inspected the facility, conducted health and safety checks on residents including R1, and observed no health and safety issues. LPA interviewed R1 who raised no concerns with the care they are receiving at the facility. LPA interviewed AD who stated that R1 was sent to the hospital on April 24, 2026, due to a bruise on their right eye, returned to the facility the same day, and has been on more frequent checks since then. LPA reviewed R1’s Physician’s Report dated February 2, 2026, which indicates R1 has dementia, uses a walker, and is non-ambulatory. LPA reviewed R1’s Individualized Service Plan dated December 11, 2025, which indicates R1 is a fall risk. LPA interviewed HSD who stated that R1 is a fall risk based only on having dementia and using a walker, but R1 does not have a history of frequent falls. LPA reviewed R1’s Facility Care Notes which do not document any previous falls for R1. Per HSD, on April 24, 2026, during the overnight shift between 1:30AM and 2:00AM, R1 was noted to have redness under their eye, but the redness did not appear concerning, R1 did not complain of pain, and there was no evidence that R1 had had a fall so it is unknown what caused the redness. HSD stated that during the morning shift between 7:00AM and 7:30AM, R1 was observed with darker bruising under their right eye, did not complain of pain, paramedics were called, and although R1 did not complain of pain, the paramedics took R1 to the hospital because R1 was on blood thinners. Per HSD, R1 returned to the facility later that same day with no fractures and the only concern noted by the hospital was that one of R1’s pupils is larger than the other, but this has been the case since R1 was young due to an accident. LPA reviewed R1’s Hospital Medical Records dated April 24, 2026, which indicate R1 had no fractures or injuries other than a bruise on their right eye. LPA interviewed R1’s responsible party who confirmed R1 has had different sized pupils since before they moved into the facility and reported no concerns with how the facility handled R1’s eye injury. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.