complaint·May 7, 2021

LPA interviewed 3 Staff who work closely with Resident #1 and all stated that the resident had an unwitnessed fall. The morning staff found R1 on the floor around 8am, while doing round checks and passing out medication at the same time. Staff immediately called for assistance from other caregivers. R1 complained of pain on the left arm and left leg, therefore, Staff called for the ambulance to escort R1 to the hospital. Staff stated that R1 requires assistance but does not have a one-to-one caregiver. Staff also indicated that R1 does not ask for assistance often and since the room door is normally left ajar, they would check on resident more frequently. According to staff, R1 did not have any previous falls. LPA reviewed the Physician’s Report for R1 which indicated that resident is wheelchair bound but is able to communicate needs and does not require continuous bed care. LPA also interviewed 7 residents who all indicated that the staff would check on them often and if they request for assistance, staff would come quickly. Based on interviews conducted, there was no indication of neglect or lack of supervision coming from facility staff. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. A telephonic exit interview was conducted with the Administrator. A hard copy of this report was emailed for a signature and the appeal rights were also provided.