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13 | At approximately 11:00 a.m. on 05/21/26 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit.
Regarding the allegation "Staff did not prevent a resident from sustaining fractures while in care" it was alleged Resident #1 (R1) suffered seven (07) fractured ribs while under staff supervision. To investigate the allegation above, LPA conducted an initial visit on 05/14/26 and interviewed the administrator at 11:15 a.m., requested pertinent records at 11:30 a.m., and toured the facility at 11:40 a.m. Today, LPA Reed toured the facility inside and out at 11:15 a.m., conducted a review of pertinent records, including but not limited to R1’s admission agreement, medical assessment, care plan, staff and client rosters, resident sign in and sign out logs, and a copy of the Adult Protective Services (APS) report filed by the facility administrator for suspected neglect/abuse of R1 at 11:30 a.m., and interviewed staff between 12:30 p.m. and 2:30 p.m. Record review of staff notes and emails revealed R1 returned to the facility from a vacation at 1:45 a.m. on 05/09/26 with a soiled diaper and high blood sugar. |