complaint·January 16, 2024

PAGE 2 OF 3. On 08/08/2023, R1 was admitted to the hospital after a fall. The review of R1’s medical records noted that R1 was not safe to go back to the facility. R1’s active problems included impaired mobility and activities of daily living and muscle weakness. However, since R1 refused to go to a skilled nursing facility R1 was referred to Home Health. On 08/18/2023, the hospital case worker spoke with two staff at the facility and advised of the discharge and referral to home health. On 08/19/2023, R1 was discharged back to the facility. Based on the facility's protocols, resident was placed under alert charting for return from hospital and staff were to monitor R1 for 72 hours. Based on staff interview, 6 out of 6 staff stated that R1 was independent. Staff was unaware that R1 was on a 72-hour check and stated that staff was not checking on R1 as they were supposed to. Based on record review, there is only documentation that staff noted R1’s condition on 08/19/2023 and 08/21/2023. There is no documentation that R1’s condition was monitored on 08/20/2023. During staff interviews, it was also observed that R1 was not feeling well on 08/24/2023, however, there was no documentation of communication between staff nor of R1’s condition that day. On 08/27/2023, at 0750 hours, staff found R1 on his/her bedroom floor with dried blood and injuries to his/her body including a golf size bump on his/her forehead. Staff called 911 and R1 was transported to the hospital where it was noted that R1 had a bump on his/her forehead with redness and discoloration on the right side of his/her right eye, skin tear on his/her right elbow and on his/her hands and knees. Based on interview, R1 reported to be getting ready for bedtime, when R1 fell and hit his/her head on the night stand. R1 was on the floor and tried calling out for staff help, however, no one responded. R1 was not checked by the staff throughout that night and was found the morning of 08/27/2023 after calling out for help. Based on staff interview, when R1 was found on the floor, R1 had ants on his/her body. PAGE 3 OF 3. The review of records shows that R1’s service plan was updated on 08/20/2023. The updated service plan did not include any diagnosis and specific needs relating to R1’s condition after being discharged from the hospital on 08/19/2023. R1’s service plan also did not indicate the need for assistance in ambulation, despite R1’s hospital discharge paperwork stating that R1 had impaired mobility and activities of daily living (ADLs), and muscle weakness. R1 was noted to be a moderate fall risk, however, the facility did not implement any additional measures to ensure R1’s safety in the facility knowing R1 is a fall risk. There is also no documentation of any refusal of care. According to R1’s residency and service agreement, the facility’s responsibility was to regularly observe the residents health status to identify social and health care needs and provide the residents with needed consultations regarding social and health related issues. In the agreement, it was also stated that “the resident’s rights shall not be limited in any way by us or team members, except where it may be necessary for the health and safety of the residents.” Based on observation from the Department’s unannounced visits on 08/03/2023 and 11/09/2023, LPA Dolores observed ants on the floor of resident (R2)’s bedroom and ants along the walls of the Business Office Director’s office. Based on interview, the facility has ongoing issues with ants and currently has a contract with a pest control to eliminate the issue. The Department has investigated the above allegations. Based on record review, interview and observation conducted the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC9099-D. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty for violation resulting in serious injury is pending review. This report was reviewed with Kippie Castronovo and a copy of the report and appeal rights was provided.