complaint·May 28, 2025

The investigation revealed the following: Allegation: Staff did not provide adequate care and supervision to a resident ON 12/2/24 LPA Felisa Shirley reviewed facility records. Per incident report dated 11/5/24, On 11/3/24 R-1 fell in the shower and was found the next morning by facility staff. LPA conducted a review of Appraisals/Needs and Services dated 5/17/24, which shows that R-1 was independent and did not require assistance with their activities of daily living such as bathing, grooming and able to feed herself. It was noted that staff should promote independency where tolerated. Per R-1’s Physician Report dated 10/30/24, R-1 was non-ambulatory, and was able to bathe, dress and groom themself. LPA Shirley observed that none of the records stated R1 was a fall risk. Per facilities Assisted Living Shower Sheet, R-1 is not listed as needing assistance with bathing. On 1/15/25 LPA Shirley reviewed staff schedule for the dates of 11/3/24 and early hours of 11/4/24. Per the schedule, there were 5 staff scheduled between the hours of 2pm and 6:30am. ON 12/2/24 LPA Shirely interviewed Facility Administrator Brittany Kavanaugh. Per interview with Administrator, R-1 was not a fall risk and walked with the assistance of a walker. No unsteadiness was noted in her gait. On 12/2/24, LPA Shirley interviewed staff 1 thru staff 10(S-1 thru S-10), of those interviewed, 9 out of 10 denied the allegation with 1 staff answering with something other than confirming or denying the allegation. On 12/2/24, LPA Shirley interviewed residents 2 thru resident 7 (R-2 thru R-7), of those interviewed, 6 out of 6 answered denied the allegation. LPA was attempted to interview R-1 but was unable as they were hospitalized. Con'd on 9099-C Based on interviews, available evidence, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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. There were no deficiencies cited. A copy of this report was provided to the Executive Director Brittany Kavanaugh. There were no deficiencies cited. An exit interview was conducted.