complaint·November 1, 2023

Allegation: Personal Rights - Staff did not address a resident change in medical condition However, based on interview with staff and W1, hospice was notified whenever staff observed a change in condition and nurse from hospice was requested by facility to assess resident. R1 was admitted to facility on January of 2022 and AGPA observed Personal Service Plan was updated, 3/4/22, and 8/22/2022 to address R1’s change in condition. Allegation: Personal Rights - Resident sustained injuries from multiple falls while in care Based on record review of incident report and progress notes, R1 had multiple unwitnessed falls on 1/28/22, 3/17/22, 8/12/22, and 8/14/22. However, no injuries were noted. R1 was admitted to ER on 3/17/22 and xray was completed, but no fractures were sustained from the fall. Allegation: Personal Rights - Staff did not follow a resident's care plan while in care Based on interview with W1, facility was following resident’s care plan and was in communication with hospice. W1 did not feel that there was any neglect by the facility according to the records from the nurses in charge during the time R1 was under hospice care. Allegation: Personal Rights - Staff did not properly report incidents involving a resident Based on record review, responsible party was notified of R1’s multiple falls that occurred on 1/28/22, 3/17/22, 8/12/22, and 8/14/22. Allegation: Personal Rights - Staff did not provide adequate care and supervision to a resident Based on record review, facility addressed the concern with R1’s responsible party regarding R1’s multiple falls. A care conference was held on 8/15/2022 where facility recommended a 1:1 companion for R1 due to increased agitation. However, R1’s responsible party refused. R1 was being checked by staff every 2 hours. 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 copy of report provided to Life Enrichment Manager. Allegation: Personal Rights - Questionable Death The Department obtained a copy of R1’s death certificate where it indicates that the cause of death was due to chronic congestive heart failure and coronary artery disease. R1 was admitted to hospice on July 25, 2022 and was diagnosed with heart failure and not related due to neglect of the facility. This agency has investigated the complaint alleging questionable death. We have found that the complaint was UNFOUNDED , meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided to Life Enrichment Manager.