complaint·June 4, 2025

Upon admission, R1 was provided with a pendant to press in case of any emergency, including falls. Additionally, each resident’s room is equipped with a call button that any resident can use to request assistance from facility caregivers or staff. During the record review, LPA Haddadin found six incident reports. Five of these six incidents were falls where the resident used her pendant; however, none resulted in injuries or hospitalization. LPA Haddadin noted that for all fall incidents, a caregiver and a nurse were present, an immediate body check was performed, and blood pressure and oxygen levels were measured, all of which were within normal range. Furthermore, the facility had placed R1 on 72-hour alert charting, during which she was very closely monitored. One documented incident occurred on October 6th. R1 requested medication, having forgotten, due to her confused state of mind and cognitive ability, that staff had already administered it. According to the report, R1 became more agitated, rose from her wheelchair, and began to yell in the hallway, asking for 911. Staff and the nurse on duty calmed R1 down and were able to control the situation. R1’s responsible party was notified of this incident and advised the facility to call 911. Emergency Medical Technicians (EMT) were called for assistance, but R1 was not transferred to the hospital due to her refusal. R1's son was informed and thanked the facility for their hard work. R1’s responsible party advised the facility that R1 could lose her temper and become loud but thanked the facility staff and praised them for their patience. LPA Haddadin conducted interviews with six staff members from different positions and titles within the facility. All interviewees corroborated that the alleged falling incidents occurred. However, these interviews revealed that the facility provided the necessary care and supervision required to assist R1. Conclusion: Therefore, based on the preponderance of evidence gathered through interviews, medical record reviews, and all pertinent paperwork collected by LPA Haddadin, the allegation, "Facility failed to provide care and supervision resulting in multiple falls," was found to be unfounded. This means the allegation was determined to be false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited during today's visit. An exit interview was conducted with the ED, and a copy of this report was provided.