Facility Evaluation Report

Licensing Program Analyst (LPA) Emily Peraldi conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20241113085831). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation. At 11:15 a.m., the LPA met with staff and explained the reason for the visit. At 11:17 a.m., the Executive Director (ED) Kenneth "Ken" Mahler met with the LPA.

During the complaint investigation of complaint # 29-AS-20241113085831, the following deficiencies was observed: Per record review, Resident #1 (R1) had multiple falls and hospitalizations between October 2024 and January 2025. The timeline of R1’s falls and hospitalizations are as follows: 10/15/2024 - R1 had a fall resulting in a left-sided facial contusion; 11/06/2024- R1 had a fall while two (2) caregivers were assisting R1 with dressing resulting in R1 having a subdural hematoma and being sent to a Skilled Nursing Facility (SNF); 12/25/2024- R1 was sent to the hospital due to being lethargic and returned with Home Health orders; 01/01/2025- R1 had a fall and was hospitalized. Per hospital records, R1 was admitted to the hospital on 11/06/2024 with the reason for admission listed as “fall and subdural hematoma” and was discharged on 11/12/2024. Per interviews with staff and record review, R1 was transferred and admitted to a Skilled Nursing Facility (SNF) on 11/12/2024 with the principal diagnosis of “Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter.” During a record review, the LPA did not observe an updated reappraisal for R1 after R1’s fall of 11/06/2024. R1 did have a reassessment/ reappraisal on 10/17/2024 after R1’s 10/15/2024 fall. Per the 10/17/2024 reappraisal/ care plan, R1 required “Complete Assist (x2 per day)” for dressing and “extensive assist” with bathing. Staff neglect led to R1’s basic services not being met and a fall on 11/06/2024 resulted in R1 having a subdural hematoma.