Facility Evaluation Report

On October 20, 2022, Licensing Program Analyst Rebecca Ruiz met with Executive Director Charles Bloom for a Case Management visit to follow-up on a substantiated allegation of staff did not seek medical attention for a resident.

On February 28, 2022, the Department received a complaint alleging staff did not seek medical attention for a resident (R1). The Department conducted an investigation which revealed on February 25, 2022, at 5:15 a.m. S1 found R1 on the floor, but S1 left R1 unattended on the floor without conducting an assessment or calling for assistance reportedly due to her behavior.

Based on staff interviews, at approximately 7:00 a.m., Staff 2 (S2) found R1 on the floor. S2 radioed S1 and Staff 3 (S3) and they assisted by changing R1’s soiled clothing and placing R1 back into bed. The incident was reported to Staff 4 (S4), the facility’s LVN, who confirmed during an interview that an assessment was done on R1 and no injuries were observed. On the evening of February 25, 2022, at approximately 9:25 p.m., Staff 5 (S5) observed R1 with bruises on their face and reported them to S4 via text message photos. Per staff interviews, on February 26, 2022, at approximately 8:30 a.m. S4 returned to the facility and observed R1 hunched over holding their left side, grimacing, and with bruising on the nose. S4 reported that that 911 was contacted at 11:30 a.m. but the local fire department doesn’t have a record of the call.

On February 26, 2022 at approximately 12:45 p.m. R1’s responsible party arrived after receiving notification at approximately 11:45 a.m. After observing R1’s condition, R1’s responsible party requested emergency medical services. Subsequently, the local fire department transported R1 to the hospital. Hospital records show R1 was triaged in the emergency room at 2:07 p.m. and was admitted to the hospital for inpatient treatment at 7:05 p.m.