complaint·December 12, 2023

LPA requested and obtained Calls for Service with the local Emergency Service Agency during the time R1 was admitted. Upon review of the Calls for Service documents, there was no indication that R1 had fallen. R1 was having a medical incident during mealtime at the dining table, to prevent a fall, staff laid R1 on the floor. R1 did not fall, then 911 was called. It was founded that R1 had expired from natural causes. LPA was also able to interview the hospice nurse and obtain hospice records, there was no indication that R1 had fallen in the facility while in care. LPA obtained death certificate and it was indicated cause of death is ‘cardiorespiratory failure and hypertensive heart disease’. There was no evidence of a fall that contributed to the death on the Death Certificate. Administrator and two (2) staff all denied the allegation and reported that R1 never fell, allegation is false. Interview with residents stated that they had never witness any of the resident at the facility fall, residents stated that they always gets assistance from staff to be move around the facility. Based on inspection and interviews there is not sufficient evidence to s upport the allegation. Therefore, the allegation is unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered. It was alleged that R1 fell due to staff neglect and staff did not ensure the residents incontinence R1 were met. Upon interview of two (2) out of four (4) residents, they are happy and content with the facility, no complaints so far. An attempt interview was done for the other two (2) of the residents but was unavailable. LPA interviewed hospice nurse and was advised that the facility has always ensured the health and safety of the residents. LPA interviewed two (2) staff, licensee and administrator about the care given to the residents and stated that incontinence is changed every 2-3 hours or when residents soiled themselves. Hospice nurse witness that when residents asked for help, staff immediately attends to their needs. Administrator and two (2) staff all denied the allegation and reported that R1 incontinence care is false. Based on inspection and interviews there is no sufficient evidence to support the allegation. Therefore, the allegation is unsubstantiated at this time. No Deficiency cited during today's visit. Exit interview conducted and copy of this report signed and delivered.