complaint·January 3, 2023

On 08/23/22 an initial 10-day visit was conducted by LPA S. Stamps to initiate the investigation. On that day LPA Stamps conducted tour of the facility reviewed records and obtained copies of pertinent records. Medical records were requested by the office of Investigations on 09/08/2022. The records were reviewed by Investigator Santana on 09/13/22. Additionally, on various days 08/29/2022, 08/30/2022, 08/31/2022, 09/13/22, 09/19/22, 09/29/22 and 10/11/22 Investigator Santana conducted interviews with, R1, Hospital Social Worker, R1’s family member, R1's former Power of Attorney, facility staff, facility Administrator and on 08/26/2022 conducted interview with the complainant. Records reviewed and interviews conducted revealed the following: R1 was admitted to this facility on 09/01/18 with a diagnoses of generalized muscle weakness and poor gait. Although R1 maintains that his/her arm bruising and leg skin tear were the result of physical abuse at the facility, R1 declined to provide specifics and mentioned only that she/he slipped on water that caregivers somehow placed on the floor. Based on interviews with caregivers and paramedics, R1’s left leg skin tear is believed to have resulted from a fall off the toilet onto the floor. Facility caregivers denied physical abuse and the Investigator was informed, during his interviews, that the alleged perpetrator, Staff #1 (S1), has not been present at the facility since 2020. Therefore, the allegation that Staff caused injury to resident is Unsubstantiated. Investigator’s interviews with the Administrator, facility staff (S2) and R1’s primary Physician revealed that by March 2022, R1 was ambulating with a walker and was ordered physical therapy sessions, which R1 refused. The facility repeatedly instructed R1 to call for help when requiring assistance, R1 failed to do so and resulted in at least six falls between 7/20/2022 and 8/20/2022. The facility was compliant with providing tools and guidance R1 needed to safely ambulate; it complied with reporting requirements and seeking medical treatment following R1’s falls; and it took steps to minimize the recurrence of falls by arranging for adjustment of medications, replacing R1’s footwear, and installing grab bars in the bathroom. Therefore, the allegation Resident sustained multiple falls while in care is deemed Unsubstantiated at this time. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.