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32 | On 04/10/2026, between 2:32 pm - 4:00pm, the Department conducted a record review and observed the following: on 03/01/2026 at 3:39 am, the facility’s wearable monitoring system detected a fall involving the resident. According to incident notes created on 03/03/2026, the resident reported falling while reaching for a remote and landing on their buttocks, which was also documented in a facility group text message at 5:53am on the same date. The notes further indicated that at 10:24 am, the resident reported difficulty moving the left side of their body, and non-emergency medical transport was contacted for evaluation. Staff documented multiple attempts to contact the resident’s responsible party at 5:36 am, 11:30 am, and 11:41 am, with voicemail inbox full, and a text message was sent notifying the responsible party that the resident was being transported for evaluation. Staff documented that the resident was assessed with no visible injuries such as bumps or bruising. Records also showed that the resident later complained of left-side pain at 1:45 p.m. and was transported to the hospital. A progress note dated 03/02/2026 at 1:57pm indicated that the hospital initially reported no stroke on CT scan, but an MRI later confirmed a stroke. Hospital records from 03/01/2026 - 03/05/2026 documented that the resident was admitted with left-sided weakness. A CT scan initially showed no acute findings. An MRI performed on 03/01/2026 revealed an “acute/recent patchy infarct in the posterior right frontal lobe/precentral gyrus,” confirming an acute ischemic stroke. The resident remained hospitalized through 03/05/2026, receiving dual antiplatelet therapy, statin therapy, neurological monitoring, and rehabilitative services.
Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.
Exit interview conducted with Robert Jakini (Administrator) and a copy of this report was provided. |