complaint·May 22, 2025

3 out of 7 residents who stated that they had a fall and staff responded right away and paramedics were also here quickly. 4 residents had not had a fall or seen anyone have a fall. Staff interviewed stated that Resident R1 had an assist to ground and not falls. Stated that 2 caregivers were needed and only 1 time there was a slight fall when 2 caregivers were providing assistance in a sit to stand chair and Resident R1 caught her feet under the chair and slid back and hit her head and had slight abrasion on right hip. Administrator documented specific dates in which assist to ground was done during transfer: 01/07/24- Resident R1 fell to knees with no injury. 04/11/24- Assist to ground no injury. 06/05/21- Assist to ground no injury. 06/26/24- Assist to ground no injury. 07/02/24- With staff and slipped from shower chair 07/21/24- Transfer with 2 staff with foot stuck under the chair causing Resident R1 to slide to to the floor. Administrator stated that staff were always assisting Resident R1 with transfers and that they were not falls. Stated that they were assist to ground. Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24 6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24. 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. In regards to the allegation Staff performed an unsafe transfer resulting in resident sustaining an injury, based on interviews conducted and information gathered it was revealed that 3 of 7 residents had needed a transfer and stated that staff did a good job. 4 residents stated that the staff are never neglectful. Staff stated that Resident R1 needed assistance by 2 caregivers and only had 1 incident in which Resident R1 caught her feet under the chair and slid back and hit her head and had slight abrasion on right hip. Stated Resident R1 was never neglected and the facility responded right away sending Resident R1 to the hospital. Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24 6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24. 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. In regards to the allegation Resident developed a pressure injury due to staff neglect, it was revealed in hospital documentation from Huntington Health that Resident R1 was seen on 07/21/24 and it's noted bilateral heels not a pressure injury. Right hip listed as abrasion. Buttocks, groin- erychema not a pressure injury. Resident's 2-8 stated that they never had a pressure injury and do not know of any residents who do. Staff stated that hospital notes show no pressure injuries. Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24 6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24. 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. In regards to the allegation Resident’s condition worsened due to staff neglect, based on interviews conducted and information gathered Resident's R2- R8 stated that staff have been great at assisting them and their condition has never worsened. Staff stated that in regards to Resident R1 she was seen every hour. Also stated that Resident R1 was seen weekly by the primary care physician. Stated that some medication Resident R1 was taking can lead to bruising. In addition with 2 caregivers assisting they have to hold Resident R1 tight so not to fall to the ground which could lead to slight bruising. Documentation from the primary care doctor reveals that Resident R1 was seen on 1/4/24, 1/11/24,1/18/24,2/1/24,2/8/24, 2/15/24, 2/22/24, 3/4/24, 319/24,6/7/24 6/14/24, 6/21/24, 6/28/24, 7/5/24, 7/12/24 and 7/19/24. 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. In regards to the allegation Staff isolated resident in her room, based on interviews conducted and information gathered Resident's R2- R8 all stated that staff will check on them daily and are never neglectful. Stated that if not in their room staff will assist if needed at dining room or other areas in the facility. Staff stated that Resident R1 would get visits hourly for assistance for Resident R1 and her spouse. Also stated they would go to their room constantly to reposition so they could prevent any sores from occurring. It should be noted that the last day Resident R1 resided at the facility was 07/21/24. 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.