complaint·May 21, 2025

The investigation revealed the following: Allegation: Facility staff neglect is resulting in residents suffering from multiple falls On 5/21/25, LPA Shirley reviewed special incident reports from January 2025 to April 2025. During review of the incident reports LPA Shirley observed 8 incident reports that were resident falls. File review revealed that one resident, R5, is considered a fall risk. R5 fell on 2/1/25 and 4/30/25. LPA observed that there was an assessment completed on 3/30/25, and interview with the Wellness Director stating that there was a care plan in place. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff neglect result in residents suffering from multiple falls. Of those interviewed, 9 out of 9 staff answered no. LPA interviewed Resident-1 thru Resident-10 (R-1 thru R-10). LPA asked, does staff neglect result in residents suffering from multiple falls. Of those interviewed, 5 out of 10 answered yes, and 5 answered no. Allegation: Facility staff not seeking medical assistance for residents in a timely manner On 5/21/25, LPA Shirley reviewed special incident reports from January 2025 to April 2025. During review of the incident reports LPA Shirley observed that residents were assisted timely by staff members upon request by residents, per incident occurrences or by observation. LPA Shirley reviewed the Acute Care Transfer log received on 5/8/25 and 5/21/25 regarding staff assisting residents by transferring the residents from this facility and the reasons for the transfers. Con'd on 9099-C LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff seek medical assistance for residents in a timely manner. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-10 (R-1 thru R-10). LPA asked, does staff provide medical assistance for you in a timely manner. Of those interviewed, 5 out of 10 answered yes, and 5 answered no. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Regarding the allegations, the Department found no evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, as a result, the allegations are Unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Wellness Director Brooke LaMotte.