Clients sustained injuries due to lack of care and supervision from staff. - UNSUBSTANTIATED

It was alleged that staff left clients unsupervised resulting in injuries.

LPA reviewed incident report dated 05/28/2024 reporting at 10:07 AM C1 was found on the floor of their bedroom. C1 did not want to stand on their own. 911 was called, C1 was transported to ER and was subsequently diagnosed and hospitalized for a fractured hip. This incident was not reported to Licensing with the required reporting time frame.

LPA reviewed an incident report dated 05/14/2025 reporting that C1 had a swollen wrist in the morning, was transported to the ER and diagnosed with a broken wrist. C1 was instructed by the hospital to follow up with primary care provider and orthopedic surgeon.

LPA reviewed Appointment Information Sheet dated 06/12/2025 that includes information about a referral being needed for DEXA scan which uses low dose X-rays to see how dense (or strong) a person’s bones are. A follow up appointment for bones/weight loss was scheduled for September 10, 2025.

LPA reviewed a referral order to oncologist dated 06/12/2025. This referral was made by C1’s primary care physician. The reason for the referral was unintentional, abnormal weight loss despite large appetite. It was noted that C1 had bilateral wrist and hip fracture in the last three years. The assessment plan includes an order for bone density tests related to the fractures and an oncologist referral related to the abnormal weight loss.

LPA reviewed an incident report dated 03/01/2025 which states that Client 2 (C2) was attempting to get out of the way of another client who was having a behavior. C2 slipped, fell and sustained a laceration to their elbow. C2 was transported to ER to receive medical attention for the laceration.

LPA reviewed ER discharge document dated 03/01/2025 which documents that Client 2 (C2) was seen in the ER and treated for a laceration of left elbow with sutures.

Administrator stated they don’t know if C1 fell. NOC staff went to check on C1 at 5:00 am and their wrist looked swollen so staff took C1 to the ER. C2 had a laceration over six months ago and staff determined that it was beyond first aid took C2 to the hospital immediately.

It was determined that C1 sustained a fractured hip and wrist one year apart. These incidents occurred at night, were unwitnessed, and therefore the causes of the fractures are unknown. Staff check on clients 3 to 4 times each night. C1 is currently being treated for abnormal weight loss, has had bone density tests performed, and is waiting for these test results. C2 was injured during a witnessed fall. There is no evidence that the clients sustained injuries as a result of lack of care and supervision. This allegation is unsubstantiated.

LPA will be issuing a citation related to the incident that occurred on 05/18/2024 for the fractured hip as this incident was not reported to LPA within the reporting requirement time frame. This citation will be issued in a separate case management report.

Staff handled client in a rough manner.- UNSUBSTANTIATED

It was alleged that staff are always pulling on Client 1 resulting in injuries.

No staff who were interviewed had witnessed anyone pulling on C1.

Administrator stated they had not witnessed or heard about any staff pulling in C1 or handling them in a rough manner.

This allegation is unsubstantiated.

It was alleged that staff isolate a client in their room.

No staff who were interviewed have witnessed C1 being isolated in their room.

Administrator stated they had not witnessed or heard about any staff isolating C1 to their room.

This allegation is unsubstantiated.

Staff yelled at clients.- UNSUBSTANTIATED

It was alleged that staff yells at clients.

No staff who were interviewed have witnessed any staff yelling at the clients.

Administrator stated that the house manager does joke around with C2 but she had not witnessed or heard about the house manager yelling at C2.

This allegation is unsubstantiated.

Staff smoking marijuana on the premises in the presence of clients . - UNSUBSTANTIATED

It was alleged that staff smoke marijuana in the facility office while clients are present in the home.

No staff who were interviewed witnessed any staff smoking marijuana in the facility.

Administrator stated they had not witnessed or heard about staff smoking marijuana in the facility.

This allegation is unsubstantiated.

It was alleged that staff leave clients in soiled briefs.

LPA reviewed care tasks for two clients, these tasks report that both clients are checked for soiled Depend every two hours.

During staff interviews it was learned that staff check on the clients 3 to 4 times a night to see if they need to be changed.

Administrator stated there are 3 clients who wear adult diapers. One client wears them all day and night and 2 wear them at night only. C2 is checked every two hours, C1 every hour, two other clients get up several times a night.. C2 usually gets up and goes to the bathroom. At 6:00 AM they all take a medication and staff checks them to see if they need to be changed and then they go back to bed.

This allegation is unsubstantiated.

This agency has investigated the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Chantelle Browning.