complaint·January 27, 2023

...continued from LIC9099 During the investigation, LPAs interviewed three (3) Staff (ADM, S1, S2) and one (1) Witness (W1), collected and reviewed documents. Records and interviews revealed although R1 was a fall risk, R1 resided on the Independent Living side and was transferred to Assisted Living on . R1’s Admission Agreement signed 07/14/2017, effective 07/29/17, stated the following: Apartment Type: Large Sierra -IL, Apartment Number: 316, Service Plan Type: Independent Living. The facility’s Nurse Notes documented a history of witnessed and unwitnessed falls from 02/18/20 to 08/22/20; on 06/25/20, S2 recommended a higher level of care for R1 which would also more cost effective. S2 stated that they were calling R1's son very regularly but was adamant about R1 maintaining his/her independence. The facility's policy for head injuries is to call the medics immediately. R1’s son provided the facility with rubber non-skid products to reinforce R1’s bed legs and S2 witnessed a rug in place to mitigate the falls. Page sixty-eight (68) states R1 was assigned to apartment (apt) 223 in Memory Care but addendum was corrected to apt 331 for Assisted Living. R1 was receiving Hospice services and died 12/29/20. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted. A copy of this report provided to Tamra Tsanos, ED