complaint·September 18, 2025

Due to lack of supervision, resident had multiple falls with injury. It was alleged that due to lack of supervision, Resident #1 (R1) had multiple falls with bruises and not enough assistance was provided based on R1’s need. To investigate this allegation on 03/20/2025, LPA conducted interviews with the Executive Director , Wellness Director/LVN, and two MedTechs, and it was revealed that R1 only had one known fall on 03/11/2025 and proper assistance was being provided by assessing R1 for injuries and pain. Additionally, on 03/12/2025, R1 was offered to be taken to the hospital; however, R1’s family refused to let the facility take R1 to the hospital and instead took R1 to the hospital themselves. Furthermore, LPA reviewed R1’s medical records and observed that on 03/13/2025, R1 was provided wound care consult at the hospital. During the wound care consult, it was revealed that due to the falls R1 had bilateral arms bruising and abrasions, redness to left breast, bilateral groin and perineal areas, right foot bruising on dorsal and planar area, and left knee/leg abrasion. Moreover, during the initial visit, LPA conducted a file review of R1 and observed that last Physician report was dated 05/23/2023, and R1 was diagnosed with Mild Cognitive Impairment and Fibromyalgia (impaired balance and muscle weakness). LPA also did not observe that the facility either notified R1's Physician nor updated the Appraisal Needs and Services Plan to meet and address R1’s needs appropriately. Lastly, during the initial visit on 03/20/2025, LPA interviewed eight (8) out of nine (9) residents, who confirmed that not enough assistance is being provided to meet their needs. During today’s visit, LPA interviewed five (5) additional residents and one (1) out of five (5) residents interviewed stated that their care needs are not being met. Therefore, based on interviews, medical records review, and R1's facility file review this allegation is Substantiated. Deficiency issued and appeal rights explained. Exit interview conducted and copy of this report signed and delivered.