complaint·March 24, 2025

Finding: Unsubstantiated During the investigation, the department conducted residents and staff interviews, obtained and reviewed R1’s including medical records, Suncrest Hospice Records, care notes, death Certificate. On 09/08/2023, R1 fell out of her bed and sustained bruising to R1 chest and back. Staff did not call 911 and called Suncrest hospice to have R1 assessed for injuries. The hospice stated that R1 did not have any injuries after her initial fall. Staff admitted that R1 was a fall risk due to her “wiggling” out of R1 wheelchair. Staff confirmed that R1 never fell out of Hoyer lift, was never transferred by one caregiver, and was a two person assist. Staff admitted that they would place R1 in the middle of the bed and face R1 toward the wall so that R1 would not fall out of the bed. S7 admitted that R1 bruises came from R1 falling out of her bed at the facility. Allegation: Staff did not provide resident with pain medication Finding: Unsubstantiated On 9/9/2023, 9/13/2023, 9/14/2023, 9/18/24, 9/20/2023, 9/21/2023, and 9/24/2024 Skilled nursing visit stated R1 seemed comfortable with no indication of pain. R1 did not have a routine pain medication. On 9/12/2023 Medical Social Worker (MSW)- Visit Notes- Observed to be well groomed and no pain behavioral issues. Care staff (S2 and S3) stated “With R1 we are trained to observed R1 pain by, R1 body language, and facial expression. During those time that S2 and S3 are assisting R1 if S2, and S3 noticed R1 have anybody/ facial expression of pain they would notify Med-techs (S4 and S5) right away. S4 stated when S4 are notified by S2 or S3 S4 would attend to R1 with a floor Nurse and evaluate R1 pain level, and if R1 need PRN(Tylenol) we would provide that, but there’s no doctor ordered on a given time of PRN (as needed). S4 stated if our nurse evaluate R1 need morphine S4/ floor nurse would contact Hospice Nurse because R1 is on Hospice, and they need to give permission. S4 stated there was not a time that R1 is in pain and was not provided with pain medication. Report continue on LIC 9099c... Allegation: Staff did not safeguard resident's personal belongings. Finding: Unsubstantiated During the investigation, the department conducted residents and staff interviews. The department interviewed S2, S3, S7, and S8, all four staff was working with R1. 4 out of 4 stated that there was not a time that R1 have anything missing. They have not heard any complaint from R1 family members. 4 out of 4 stated they did not see R1 wearing anyone else clothing, nor left R1 sleeping on the bed without any bedsheet. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a report provided to ED.