complaint·July 27, 2023

In regards to the allegation "Resident sustained multiple injuries while in care" it was alleged that R1 sustained multiple injuries in care and hospitalized due to lack of supervision. (5) of (5) Staff interviewed denied the allegation. (7) of (7) Residents interviewed could not corroborate the allegation. It is alleged that R1 fell and broke their teeth on once occasion and then broke their shoulder because of a fall on another occasion. File review shows documentation of unwitnessed fall regarding R1 that resulted in R1 going to the hospital for a cut on their lip. Interview stated that staff were conducting a room check on 9/2/21 for R1 and noticed R1 had a cut on their lip. Due to it being an unwitnessed injury, staff called 911 to have R1 go to the hospital. There is no documentation or interviews from staff and residents stating that R1 broke their teeth in the facility. File review also shows documentation of a fall R1 had on 9/12/21 at approximately 1:45am near the facility elevator which resulted in a possible shoulder injury. According to interviews, R1 got out of bed in the middle of the night and went down the elevator. Upon stepping out the elevator R1 lost balance and fell. Staff interviews show that R1 was immediately assisted by staff. Interviews show that R1 liked to walk around the facility on their own and when they pleased. R1 did not require one on one supervision per review of their file. Staff interviews also stated that R1 was sent to the hospital that night but did not return to the facility as family relocated them. There are no further documents on file regarding R1's fall on 9/12/21. LPA was not provided any further documentation regarding the hospital visit or status of R1. Based on files reviewed, observations, and interviews conducted, there was not enough supportive evidence to corroborate the 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. In regards to the allegation of "Areas of potential hazard to residents with poor eyesight were not kept inaccessible to residents." it was alleged that the facility did not close off a construction zone causing R1 to fall. (5) of (5) Staff denied the allegation. (7) of (7) Residents interviewed could not corroborate the allegation. Interviews state there was a night where the facility hired an individual to fix a small section of tile in the hallway near the elevator. The work was being done between 12am-4am as to not bother residents in care or interfere with any daily activities. Signage was put upon the walls as well as caution cones places to block the area. Staff had view of the area as needed to make sure residents kept their distance. Interviews show that R1 came down the elevator from their room around this time and ignored signs and directions from staff present to not walk towards that specific area where the floor was being repaired. Based on files reviewed, observations, and interviews conducted, there was not enough supportive evidence to corroborate the 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 conducted and a copy of this report was provided.