Complaint·June 23, 2023

Received the following documents on 12/14/22: Copy of the resident complete facility file to include but not limited to Staff and Resident Roster, Needs and Service Plan for R#1, Physician Report for R#1, Medication list for R#1, SIR report R#1 and time sheets. LPA and Administrator toured the facility including 3 bathrooms, 4 bedrooms, dining room, living room and kitchen. Based on the LPA's investigation, the investigation revealed the following. Allegation – Resident sustained injuries from a fall while in care. Interviews with S#1, S#4, & S#5, they communicated that the resident's fall was un-witnessed. Resident was found by S#5 around 7am when their shift began. S#5 was checking in on the residents going to get them ready for the day. The resident was on the floor with residents head bleeding, but responsive. Resident was opening their eyes. S#5 communicated that S#5 asked resident what had happened and why did resident try to get out of bed on their own. Resident only looked at S#5 and stated that resident did not know what had happened. S#5 called Administrator and 911, the resident was taken to the E.R. Resident's bed had the half rails up and they are not sure how the resident got out of bed. The resident had never done that before, resident had always waited for assistance to get out of bed. Staff #3 that was working that night, did not hear, see or was aware that the resident had fallen. Staff member was taking care of another resident at the time of the incident. The last time staff #3 checked on resident was that morning around 6:40am to 6:45am and they were fine in their bed. Interviews with R#1, R#2, R#3, R#4, and R#6, communicated that they have never fallen or witnessed any other resident fall. R#5, communicated that they were the residents roommate, they shared the room. R#5, only heard the fall, but did not witness the fall. R#5, believes that there was no staff member in the room at the time of the fall. R#5, believes they were alone, but they are not too sure because the rails were up on their bed and the rails obstructed their view. LPA Soto reviewed resident physician's report dated 05/14/21, resident required assistance with all their ADL's and was diagnosed with Dementia. Resident could walk, but with assistance from the staff. LPA reviewed resident's Daily schedule, resident was given a bed alarm to be placed on resident bed rails to go off when resident moved out of bed. Resident's family provided the alarm. S#1 communicated that the alarm had broken about 6 months prior to the incident and they informed the family, so they could replace the alarm but family never replaced the alarm for their resident. Interviews and records review did not concur with the above 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. An exit interview was conducted with Krystal Adams, Administrator, and a hard copy of report was provided.