It is being alleged that R1 fracture R1 hip while in care of staff. Toured the facility including R1 room. R1 room floor did not appear to have any wax on the ground. Incident report (dated 01/28/2024) R1 fell in room and was not injured. Incident report (dated 03/29/2024) staff noted R1 had leg injury and R1 was transported to St. Mary hospital for evaluation. S1 indicates that R1 was no longer living at the facility in June 2024. S1 indicates that there is no record of R1 falling on 06/08/2024. S1 indicates that St. Mary hospital records has R1 in room 255 on 03/29/2024 for infection of the left foot. S1 indicates that the hospital does not mention a fracture hip for R1. 4 out of 4 staff indicate that R1 never fracture R1 hip while in care of staff. R1 indicates that R1 was moving from R1 wheelchair to the bed. R1 indicates that due to a wet floor R1 fell and fracture R1 hip on 06/08/2024. 10 out of 11 residents indicate that they have never seen staff wax the floors or rooms. 10 out of 11 residents indicate that they have never fracture their hip.

Regarding Allegation #2: Unlawful eviction.

It is being alleged that R1 was evicted from the facility unlawfully. Reviewed 30-day notice of eviction, (dated 02/19/2024), effective date of eviction 03/19/2024, due to past due rent and late fees. S1 indicates that R1 was behind in R1 rent and stopped paying any rent since March 2024. S1 indicates that R1 was transported to St. Mary Hospital on 03/29/2024 and never returned to the facility. S1 indicates that a 30-day notice was generated on 02/19/2024 and effective 03/19/2024. S1 indicates that R1 was served the eviction notice by staff S5 while living at the facility. S5 indicates that S5 was given the 30-day notice of eviction and gave the notice to R1 prior to R1 being taken to the hospital on 03/29/2024. R1 indicates that R1 was transported to the hospital for a fracture hip on 06/08/2024. R1 indicates that R1 was released from the hospital. R1 indicates that the hospital informed R1 that R1 had been evicted from the facility and could not return. R1 indicates that R1 was never given an eviction notice from the facility. R1 indicates that R1 had not paid R1 rent and had text the facility owner to work out a solution but R1 never returned to the facility. 10 out of 11 residents have never received an eviction notice from the facility.

It is being alleged that R1 had fallen in R1 room and called for help from staff. LPA Calderon toured the facility to include room 134, 220, 277 and 282. One of the rooms inspected was R1 room. LPA pushed the call button and on average it took staff 5 to 10 minutes to arrive. Reviewed call log notes (dated 03/05/2024), there are no call logs from R1 room from March to June 2024. There is no incident report for 6/8/2024 for R1 falling and fracture R1 hip or R1 pressing the call button. 5 out of 5 staff indicate that on average it takes 5 to 10 minutes for staff to help once a call button is pushed. 5 out of 5 staff indicate that there is no record of R1 pushing R1 call button on 06/08/2024. S1 indicates that R1 was no longer living at the facility on 06/08/2024 and had been at St. Mary Hospital since 03/29/2024 for a foot injury. R1 indicates that on 06/08/2024 R1 fell and fracture R1 hip. R1 indicates that R1 pushed the call button for help, and it took staff 2 hours to arrive and call 911 for R1 to be taken to the hospital. 10 out of 11 residents indicate that it takes 10 to 15 minutes for staff to arrive once a room call button is pressed.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations of “resident sustained fracture while in care of staff”, “unlawful eviction”, “staff did not assist resident in a timely manner” is found to be UNSUBSTANTIATED.