complaint·January 6, 2023

Allegation: Resident sustained multiple falls resulting in injuries Based on records review, it was revealed that on 12/21/2020 R1 was found on the bathroom shower floor, staff called 9-1-1 but resident refused to go to the hospital. Staff called R1’s family and informed the incident. Based on records review, R1 had bruises from the fall incident on 12/21/2021, however R1’s care plan stated that R1 is independent in toileting needs and staff was advised to just monitor and notify supervisor if any evidence of odor or toileting needs. Allegation: Staff are mismanaging residents’ medication Based on records review, medication administration records (MAR) revealed that staff gave R1’s medication according to physician’s order. R1’s MAR revealed there was no miss medications and discontinued medication was stopped per doctor’s order. Allegation: Staff are not treating residents equally During the course of investigation, LPA interviewed staff and residents. Based on residents’ interview, they denied any unequal treatment from staff. Staff stated that all residents are treated equally according to each residents needs since each residents have unique needs. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.