complaint·August 26, 2024

Interviews conducted with staff revealed that on 12/27/23 at around 11:00pm staff responded to R1’s pendant call. Once staff arrived at the room, they found R1 seating in the floor, with blood dripping from the head. R1 stated to have hit the head. Staff assisted and notified R1 that they will contact 911. R1 refused medical care. However, staff contacted 911 per protocol and send R1 out to be evaluated. Staff stated they contacted the family to notify of incident and no additional information was requested after the initial contact. Documents reviewed revealed incident report dated: 1/10/24 was submitted to the department to report the incident occurred on 12/27/23 regarding R1’s fall and assistance provided. Per incident report R1’s family member was notified of incident on the same day. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are retaining residents that require a higher level of care. It is alleged facility’s staff retained R1 and several residents with dementia in the assisted living. Interviews conducted with management team revealed that there are currently 3 residents from assisted living with a dementia diagnosis and waiting for an opening in their dementia unit. Per administrator the dementia unit is full and has a waiting list from which the residents from the assisted living have priority. The three residents have been diagnosed with dementia within the last 8 months, and are either under care with a private caregiver or are under hospice services. Management staff spoke with R1’s responsible party regarding change in condition and R1’s need of higher level of care. Documents reviewed revealed 3 out of 7 residents’ physician’s reports note residents have a dementia diagnosis which was updated within the last 8 months as the diagnosis was not noted on their previous physician’s report. One of these residents is on hospice care, another has a private care giver, and the last one has a location device in place. Facility has set up hourly safety checks for the residents, they provide a concierge at the lobby to observe who enters and exits the facility, and a sound device is located in their doors to alert staff that the residents have exit the rooms. Even though there are residents with dementia in the assisted living the facility is taking precautions and following regulations to provide care for these residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted and a copy of this report was provided.