complaint·October 10, 2023

***** This report supersedes the original complaint investigation report dated 8/17/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.***** The investigation revealed the following: in regards to the allegation "lack of care and supervision resulted in multiple falls and an injury" , it is alleged that R1 suffered multiple falls between June & July 2020 as a result of facility's lack of supervision and lack of communication amongst facility staff. R1 did not have a one-to-one caregiver while a resident of the facility. Interviews conducted with staff members denied the allegation. Staff members interviewed indicated that they will debrief each other during shift changes to make sure they are aware of what happened during the shift before theirs. Staff members indicated they utilize a communication binder and a whiteboard located in the medication room to keep track and log any changes in resident conditions. The communication binder contained community incident reports that were completed if there were incidents to be reported. Room checks were conducted every 2 hrs or as needed depending on the residents' needs. It was also indicated that the staff were aware of resident's falls and both the communication binder and whiteboard aided Caregivers in monitoring residents. LPA reviewed R1’s Resident Assessment Care Agreement (June 2020) showing personal Care Services and Care Plan under Memory Care (MC) unit. It indicated personal care for gait/balance and status checks due to having episodes and recent history of falls thus requiring safety status checks for fall prevention. Staff members interviewed indicated they do their best to keep residents from falling. Facility documented and reported R1's falls to Licensing. LPA reviewed the hospice records and community incident reports (Oct. 2020-Nov. 2020) regarding the resident’s falls which indicated that they were reported to Hospice, doctor, and Family member. Additionally, the reports indicated that there were no falls that led to injury that needed hospitalization and/or need to relinquish Hospice Services for Hospitalization . Facility also sought timely medical attention for R1 after her falls. Residents interviewed also denied the allegation. Residents interviewed indicated that they are happy with facility staff and the services they receive at the facility. LPA also reviewed the death report submitted to CCLD on 11/18/2020 indicating that a family member was notified on 11/13/20 at 3:45am of resident’s passing. During the tour of the Memory Care Unit, LPA observed (1) Med Tech and (2) Caregivers on duty. The staff to resident ratio at the MC Unit is to 5-7 Residents for all shifts; AM shift (6am-2pm), PM shift (2pm-10pm) and NOC shift (10pm-6am+1). Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported 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 held, and a copy of this report was provided to Maria Quizon, Administrator.