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32 | held between 9:00am to 11:00am, interviews with six (6) residents, held between 11:00am to 12:00pm, interview with home health, held between 12:00pm to 1:00pm, record review, conducted between 1:00pm to 2:00pm, and a physical plant inspection, conducted between 2:00pm to 3:00pm.
Interviews with the administrator, house manager and staff deny the allegation of neglect. The administrator and the house manager stated that on or around 05/23/26, R1 had an witnessed fall, and was found on the bedroom floor. No injuries from the result of the fall, but R1 does have a pre-existing wound injury. Paramedics and R1s family were notified, and R1 was taken to the hospital for treatment. R1 was admitted and remained in the hospital until 05/26/26. R1 was discharged with new orders regarding medication changes. Review of R1's records confirm that an Incident Report (IR) was submitted, and that R1 had a fall on 0523/26. The incident report confirmed R1 had no injuries as a result from the fall, but since R1 had a pre-existing wound infection, R1 was sent to the hospital for treatment. Additional review of R1's records reveal that R1 was previously from a rehabilitation center, prior to discharge to facility. R1 had a surgical wound to the coccyx at discharge, but no history of skin breakdown. The reason for discharge from the rehabilitation center to a board and care is because a lower of care was only needed. Home Health service was ordered to treat R1's wound injury. Interviews with R1's home health nurse does confirm that home health is treating R1 for a pre-existing wound injury. Home health is aware of R1's fall, and reports no neglect or lack of supervision on the part of licensee. Interviews with the residents do not corroborate with the allegation of neglect. Some residents confirm that their needs are met by facility staff.
Based on the information obtained, it could not be proven that R1 sustained a laceration due to staff neglect. Therefore, the allegation is deemed Unsubstantiated at this time. Administrator was advised and a copy of this report issued. |