complaint·September 6, 2024

Allegation: Lack of supervision resulted in resident sustaining a fracture while in care. It is alleged that resident (R1) had multiple in December 2023 that resulted in a fractured pelvic area. An additional fall occurred on January 7, 2024 after the resident returned from dialysis clinic. DSS Investigator Laarni Santiago conducted interviews with facility staff, resident's family members, and outside sources. Facility and medical records were reviewed and obtained. Medical records verified that R1 fell in December 2023 at the facility and was then admitted to a skilled nursing facility. Upon discharge back to the facility on January 7, 2024 the resident had another unwitnessed fall. Resident (R1) was found by facility housekeeper, whom immediately responded to the resident, and R1 was later transported to the hospital. Interviews with staff and family members verified that resident (R1) was independent with all Activities of Daily Living (ADL's); alert and oriented; able to communicate their needs; and able to navigate around their room and facility independently utilizing a walker/wheelchair. Records corroborated that resident (R1) was self-sufficient. Physician's Report stated that the resident was a fall risk due to weakness from dialysis, pain, with amputated fingers and toes. However, Primary Care Physician indicate that the resident could still manage on their own with minimal supervision. Although, R1 was known to be a fall risk due to their medical condition, the resident was compliant with maintaining the use of their assistive device and staff checked on the resident every two hours and close supervision was received while the resident was in the common area. The facility has a call light system for all residents and R1 always called staff for assistance when needed. Investigator attempted to interview R1 on 2/28/24. Resident (R1) died at a higher level facility mid-March 2024. Based on interviews and record reviews, there is insufficient evidence to prove the alleged violation occurred. 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 . Exit interview conducted with Assistant Administrator Cynthia Flores. A copy of the report was issued.