complaint·November 4, 2021

The investigation revealed the following: In regards to allegation, resident sustained injuries from a fall while in care. It is alleged that Resident #1 (R1) fell and sustained bruises underneath the eyes and swelling around the nose. LPA interviewed the Staff #1 (S1), who was on duty for the overnight shift but did not witness the fall. S1 stated that the fall occurred around 2 a.m. When S1 heard R1's fall, S1 immediately went into the room to observe R1 by the end of the bed and already standing up. S1 checked on resident for any injuries and asked what had happened. R1 responded by saying that R1 might had slipped on the wet floor but there was no pain. R1 agreed to take a Tylenol as a precaution and went to sleep right after but S1 did not observe any bruising or swelling in the face at that moment or in the morning. Per R1's family member, R1 stated that R1 either fainted or lost balance while trying to get up. R1 also refused to go to the doctor when family member went to visit that morning and noticed some redness by the nose. The licensee showed LPA a photo of R1's alleged injury from the fall but also stated it is difficult to determine if the fall caused any bruising or swelling since R1 normally has puffiness underneath the eyes. LPA interviewed the Marketing Director of Cedar Assisted Living who stated that the R1's sister informed her that R1 had a fall at the former facility. R1 was not observed with any swelling or bruises in the eye or nose area upon admission at new facility. According to interviews conducted with facility personnel, Resident #1 (R1) does not require much assistance and is able to ambulate on own. All the staff reported that R1 moves around the house using a walker sometimes but does not need staff to assist with mobility, which is also mentioned on the Appraisal/Needs and Services Plan and/or Physician's Report. However, Staff check on all residents regularly and respond right away when they hear residents' calls. LPA also interviewed 2 out of 3 residents which both stated Staff check on them and assist with their needs. Although R1 had fallen, there is no supporting evidence indicating a lack of supervision or neglect from the staff. In addition, there is no evidence to show that the fall caused any form of bruising or swelling in the eyes and nose area. 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. An exit interview was conducted with the licensee via telephone. A copy of this report along with the appeal rights were provided to the Staff whose signature on this form confirm receipt of these documents .