Complaint·November 18, 2025

Per R1’s care plan dated September 10, 2025, R1 has a diagnosis of mild cognitive impairment, congestive heart failure, atrial fibrillation, obstructive airway disease, and had a pacemaker. R1 was receiving assistance with medication, required escorts to all meals and activities of choice, and wears a wander guard for safety. Per R1’s charting notes dated September 19, 2025, R1 had an unwitnessed fall in his apartment and was found by staff on the floor around 7:30 AM. R1 was transported to the hospital for his injuries and was admitted for syncope and collapse. R1 remained in the hospital from September 19, 2025, to October 5, 2025. R1 returned to the facility on October 5, 2025, after being discharged from the hospital and was admitted under hospice with a primary diagnosis of end stage heart failure. R1 passed away on October 5, 2025. Per R1’s certificate of death, the listed causes of death are cardiopulmonary arrest and congestive heart failure. Based on a review of R1’s records, there were no records that indicated R1 was a fall risk and there were no records indicating that R1 has any previous recorded falls at the facility. Additionally, R1 did not require hourly checks by staff. LPA conducted six staff interviews. Six out of the six staff interviews conducted confirmed that the fall on September 19, 2025, was R1’s first fall while at the facility. The staff interviews conducted also denied R1 being considered a fall risk. Furthermore, it was revealed during staff interviews that R1 was provided with a call pendant upon move in which he could press to call for assistance from staff. However, R1 was not wearing his call pendant on the morning of September 19, 2025, and staff later found R1’s call pendant in his kitchen cabinet. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. Regarding the allegation that, staff did not seek timely medication attention for resident after sustaining fall, the following has been concluded: LPA reviewed R1’s charting notes dated September 19, 2025, which stated that R1 had an unwitnessed fall in his apartment and was found by staff on the floor around 7:30 AM. The charting notes stated that Staff #4 (S4) found R1 on the floor and that Staff #1 (S1) called 911 to seek medical attention for R1. LPA conducted an interview with both S1 and S4. Both staff interviewed denied the allegation and denied any delay in seeking medical attention for R1 after he was discovered on the floor. LPA reviewed S1’s personal cell phone call log and observed 911 was called at 7:37 AM on September 19, 2025, which is approximately seven minutes after R1 was discovered on the floor by staff. CONTINUED ON LIC9099-C Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Benjamin Davis and a copy of the report was provided.