complaint·November 18, 2022

Resident sustained a fracture while in care: On 4/22//2022, the Department reviewed R1's incident reports (IRs) dated 4/16/2022 and 4/18/2022, R1 had two separate fall accidents in the facility on 4/16/2022 and 4/18/2022. According to IRs, on 4/16/2022 R1 lost his/her balance and fell in the restroom. R1 was immediately sent to hospital, and was discharged on the same day. While on 4/18/2022, R1 attempted to pick up his/her water bottle from bed side, and fell on the floor and hurt his/her lower back. R1 was immediately sent to the hospital. On 6/13/2022, the Department obtained hospital medical records of R1. Based on medical record reviews, R1 had prior lumbar injuries. Based on R1's appraisal, R1 was ambulatory with no need for assistance. On 8/4/2022, LPA interviewed ADM, and two staff (S1, S2). All of them stated R1 had falls on 4/16/2022 and 4/18/2022, and was sent to hospital. ADM and S1 stated R1 had Lumbar injuries before R1 was admitted in the facility. Based on records reviewed and interviews conducted, R1 had lumbar injuries prior admission to the facility. R1 was ambulatory with no need for assistance for walking. The two fall incidents were un-witnessed, it happened in the restroom and in R1's bedroom. The Department has investigated the above allegations. Based on the investigation, observations, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED , meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview was conducted with ADM. This report was provided to ADM for signature. Facility is not sanitary: On 08/04/2022, LPA conducted an investigation/inspection visit of the facility. During visit, LPA toured and inspected the following areas in the facility: living room, dining room, kitchen, 3 bedrooms and 2 bathrooms. During the inspection, LPA did not observe feces on the wall of residents' bedrooms. LPA observed bedrooms with no feces or smell. On 8/04/2022, LPA interviewed staff (S1) and 5 residents (R1 - R5). S1 stated the facility staff check and clean the resident bedrooms everyday. S1 denied there were feces on the wall of residents' bedrooms on 4/16/2022. All of 5 residents did not complain that the facility was unsanitary. Based on investigation, observations, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM.