Complaint Investigation Report

On allegation that Staff did not issue proper refund:

It was alleged R1 was not eligible for a refund for September 2024 rent, despite moving out. On 8/23/24 Family #1 (F1) signed an Admission Agreement for Resident #1 (R1). Per admission agreement it states in the section 17, page 8 “17. Termination of Agreement: You may terminate this Agreement at any time with a 30-day written notice.” R1 went to the hospital on 9/6/24. Further evidence of understanding of this agreement is an email dated 9/6/24 at 8:31 AM from F2. The email states “My (R1’s) family has decided that the best course for (R1) is to grant (R1) request that (R1) be moved to the Texas home of (R1’s family member). This email is the (family last name) 30-day written notice of termination of their agreement with you for my (R1’s) care.” No refund for R1 is required at this time, based on the admission agreement.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

On the allegation that Staff did not seek medical attention for resident in a timely manner.

It was alleged that R1 fell out of bed on 8/30/24 and that on 8/31/24 F1 requested R1 be evaluated and was told R1 needed rest and they would monitor R1. After a week R1’s leg was getting worse per F1 and on 9/6/24 they requested the facility call 911. Determination was a Subcapital proximal femur fracture which required surgery.

On 9/17/24 at 8:57 am LPA interviewed F1 and on 9/30/24 at 3:27 pm LPA interviewed F2 regarding allegation. Both stated they visited R1 on 8/31/24 at approximately 11:00 am. F1 stated that facility informed them that R1 had “fell out of bed” the day before (8/30/24). Both informed LPA that R1 could barely talk or eat, “very groggy”. F2 stated during the visit R1 would “Talk a little and fall asleep” and “complained about right leg hurting.” F1 stated facility told them R1 “had trouble sleeping so they gave R1 extra sleeping medication.” F1 stated on 09/03/24 F1 and a friend visited R1 again and R1 was still in pain, not groggy. F1 stated only Tylenol was given but R1 had stronger medications. F1 stated on 09/06/24 they arrived early for a visit and watched as 2 female staff moved R1 to their wheelchair from a recliner. F1 stated R1 was in pain from the transfer, that R1 was loud when moved.