Complaint·March 24, 2026

The investigation consisted of the following: On 03/12/2026, interviews were conducted, medications were reviewed, and records were gathered. Resident 1 (R1) to Resident 5 (R5), Staff 1 (S1) to Staff 5 (S5), and Witness 1 (W1) were interviewed. Facility records gathered consisted of staff roster, resident roster, Resident 1’s (R1) records, and other pertinent records. On 03/13/2026, Staff 6 (S6) to Staff 10 (S10) and Witness 2 (W2) were interviewed and records were reviewed. The investigation revealed the following: Allegation: “Staff did not prevent a resident from sustaining multiple falls while in care”, it is being alleged that due to the lack of care R1 has had multiple falls. Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation and 4 out of 5 residents denied the allegation. Resident 1 indicated that they had about four falls in the facility and staff have assisted them when they fell. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Staff 10 indicated that they worked with R1 during their Admission Process/Care Plan and R1 was informed that when they require assistance with transferring/mobility to press their pendent and wait for assistance before getting out of bed; S10 goes on to explain that R1 understood what was being informed to them. Staff 9 indicated that on 01/26/2026, they had finished assisting R1 and started assisting other residents in neighboring rooms when they heard R1 fall, as soon as S9 heard the noise they went to R1’s room to assist them. Staff 9 indicated that on 03/03/2026, they were assisting R1 in the bathroom, then R1 slipped and S9 assisted R1 in a fall; R1 had an assisted fall. Interviews conducted with W1 to W2 revealed the following: 2 out of 2 witnesses indicated that R1 has a history of falls. Resident 1’s record review revealed the following: Medical Assessment for Residential Care Facilities for the Elderly dated 01/15/2026 did not indicate that R1 has a history of falls but does indicate that they require assistance with repositioning and transferring. Appraisal/Needs And Services Plan dated 01/16/2026 indicated that R1 will use a wheelchair, walker, and care staff will assist with Activities of Daily Living (ADLs). Incident Report dated 01/26/2026, indicated that care staff found R1 on the floor in their room. Incident Report dated 03/03/2026, indicated that R1 slipped in the bathroom under the supervision of care staff. Observations in R1’s room on 03/12/2026 revealed the following: R1 has a pendant button necklace and an intercom call box with button installed on the wall; the pendant was pressed at 1:36 PM, at 1:38 PM a staff spoke through the intercom, and at 1:41 PM two staff came to R1’s room. Unsubstantiated: 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. Allegation: “Facility did not ensure that staff are properly trained”, it is being alleged that Medication Technicians (MedTechs) are not trained. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Records reviewed of facility MedTechs revealed the following: All facility MedTechs have current MedTech Certificates. Observations in the Medication Room on 03/12/2026 revealed the following: Facility MedTechs knew how to do their job properly. Unsubstantiated: 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. Allegation: “Staff did not respond to resident's call button in a timely manner.” Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation and 4 out of 5 residents denied the allegation. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. Witness 2 agrees with the allegation. Observations in residents’ rooms on 03/12/2026 revealed the following: staff responded to the pressing of a pendent / intercom ranging from less than a minute to three minutes. Unsubstantiated: 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. Allegation: “Staff did not administer medication to a resident in care”, it is being alleged that R1 is not receiving their medication as prescribed. Interviews conducted with R1 to R5 revealed the following: 1 out of 5 residents agreed with the allegation and 4 out of 5 residents denied the allegation. Interviews conducted with S1 to S10 revealed the following: 10 out of 10 staff denied the allegation. On 3/12/2026, R1’s medication along with their Medication Administration Records (MARs) were reviewed and it revealed the following: R1 is receiving all their prescribed medication. Unsubstantiated: 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. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator, Monniece Boatwright.