1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Regarding the allegation: Resident sustained a head injury due to staff neglect or physical abuse. It was alleged that resident one (R1) had an unwitnessed fall resulting in bruising. To investigate the allegation, LPA attempted interviews with one (1) resident and three (3) staff members. LPA attempted to interview R1 but due to their inability to validate the questions being asked, LPA terminated the interview. LPA’s interview with S2 revealed R1 was sent to the hospital on 4/26/2026 due to staff observing discoloration of their face. S2 stated R1’s representative, who was visiting during said incident (4/25/2026), declined medical services for R1. LPA’s interview with S3 revealed R1 was placed on a head monitoring chart due to the discoloration notated on their face. Per S3, a body check, including of the head, was conducted on R1. S3 stated on 4/26/2026, R1’s representative was contacted to inform them that R1 was being sent out to the hospital as a precautionary measure. When questioned if R1 could have been struck by another resident, S3 declined but did mention an Unusual Incident/Injury Report (SIRs) was submitted for an isolated incident where R1’s representative reported to have observed a resident (R2) strike R1’s hand. LPA’s record review confirmed that the facility did report both incidents to the appropriate reporting parties including Community Care Licensing Division (CCLD).
LPA conducted a record review. LPA’s review of R1’s hospital discharge paperwork dated 4/30/2026 documented R1 to have been diagnosed with a nontraumatic hemorrhage. LPA conducted a supplementary record review, where a web search of R1’s diagnosis stated, “…bleeding that accumulates between the brain and its outer lining (dura mater) without being caused by a direct head injury…”. Further record review of R1’s discharge paperwork indicated their head scan results returned as, “stable”. Additional record review was conducted pertaining to R2. R2’s Physician’s Report regarding their behavioral expressions to document as follows: Lack of impulse control? No; Expressions of Frustration? No.
During LPA’s physical plant tour, LPA conducted random room checks in both the Assisting Living and Memory Care residencies. LPA observed residents’ rooms to be neat, clean and organized. LPA did not observe there to be any obstructions in the residents’ rooms. Additionally, LPA observed R1’s bedroom to be in proper condition with no hazards in the bedroom’s walkways. During LPA’s physical tour, LPA observed R1 to appear to be in good health and participating in activities with their peers. LPA observed staff to be present throughout both wings of the facility. LPA observed sufficient amount of staff members to be present with residents in the Memory Care Unit. LPA’s record review of the Memory Care staff schedule for 4/25/2026 and 4/26/2026 did not showcase there to be any discrepancy.
(Continue to LIC 9099-C)
|