complaint·April 22, 2021

Upon return from the hospital the facility conducted a reappraisal and R1 was transferred to the memory care unit. On 4/6/2021, R1 returned to the hospital due to lethargy. Upon arrival, according to interviews, R1 did not have any bruises. However according to facility, on 4/9/21, when R1 was discharged from the hospital, R1 returned with bruising to left eye. Interviews conducted with hospital social worker on 4/20/21 at 11:25 am revealed there was no documentation that R1 sustained bruising at the hospital. At this time due to conflicting statements there is insufficient evidence that due to facility staff neglect that R1 sustained additional bruises after the 3/15/2021 fall. This allegation is Unsubstantiated at this time. Allegation #2: Resident sustained multiple falls : There are concerns that due to facility neglect resident sustained multiple falls. During today's visit, between the hours of 9:50 am to 11:03 am, LPA conducted interviews with the Administrator, Staff, and Resident #1 (R1) relative. At 11:15 am, LPA reviewed R1's facility file which included R1's physician report, needs and services plan, incident reports, and Skin Integrity document. According to the interviews conducted, on 3/15/21, R1 was found outside on the side walk after lunch by staff. R1 was found on the the ground with bruising and blood on left side of face and scratches on hand and arm. Based on LPAs record review and interviews R1 was able to leave unassisted and would frequently leave to go on walks. According to the facility staff and R1's relative that was the only fall that R1 had at the facility. R1's relative was immediately notified and 911 was called. At this time based on record review and interviews the fall that occurred on 3/15/2021 is the only fall that R1 sustained. Therefore the allegation that R1 sustained multiple falls is Unsubstantiated at this time. Exit interview conducted. The report was signed, however a copy of the signed report was emailed.