Facility Evaluation Report

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit for the purpose of completing a Case Management Deficiency. LPA was greeted and granted entry into the facility by staff and explained the purpose of the visit.

During the investigation for complaint control number 22-AS-20250414124920, the following deficiencies were observed.

On May 13, 2025, Resident #1 (R1) had an unwitnessed ground level fall. It is unknown what time of night this fall occurred. Two of two Staff interviewed stated R1 was put to bed between 8pm and 9pm and was not checked on until the next morning. Per interviews with two of two staff & Licensee, the facility does not have awake staff at night. At 8:15am on May 14, 2025, Staff 1 (S1) and Staff 2 (S2) found R1 on the floor with a cut above R1’s left brow. Staff picked R1 up from the ground and placed R1 in a wheelchair. Staff then proceeded to clean the bedroom of the blood on the floor. Staff contacted the Licensee Lawrence Lindsey, who then called 911. Hospital records obtained show Paramedics were dispatched at 9:02am and arrived on scene at 9:07am. Due to S1 and S2 not immediately calling 9-1-1 there was an approximate 52 minute delay in R1 receiving medical attention.

Per R1’s family, R1 has had a history of recurrent falls since December 2024 and correlating with Urinary Tract Infections (UTIs). Family informed Licensee that R1 wandered at night and had been working with R1’s Primary Care Physician to manage insomnia with medications. During interview with Licensee, Licensee acknowledged knowing R1 had a tendency to wander at night and was a fall risk. Despite, knowing R1’s wander behavior, no additional staff was provided to ensure R1’s safety while wandering. When asked about fall prevention methods, Licensee stated a fall mat had not been implemented due to R1’s family not providing one and was unaware if bedrails had been ordered for R1.