complaint·June 13, 2025

It was alleged that, due to lack of care and supervision, R1 was pushed by another resident and fell, resulting in a head injury that progressed R1’s Dementia and caused R1 to be placed on hospice with a short time left to live. LPA inspected the facility, conducted health and safety checks on residents, including R1, and observed no health and safety issues. LPA attempted to interview R1, but R1 was unable to communicate. LPA interviewed the facility’s medication technician supervisor who stated that, on April 20, 2025, R1 was not pushed by another resident, but instead fell on their own, hit their head, went to the hospital, and came back that same day with stitches. LPA interviewed the three staff present during the incident, one of whom confirmed seeing R1 fall by themselves and stated they attempted to catch R1 but were unable to reach R1 in time. LPA reviewed R1’s medical records dated April 20, 2025, which confirm that R1 received treatment for a head laceration, was diagnosed with a urinary tract infection, and was released back to the facility the same day. The information obtained did not corroborate that R1’s fall was caused by an altercation with another resident. Per the facility’s medication technician supervisor, three caregivers are assigned to the second-floor memory care and the facility’s resident roster indicates there are 22 residents in the second-floor memory care. Interviews with the three staff present during the incident confirmed that the second-floor memory care was fully staffed at the time of the incident. Per the facility’s medication technician supervisor, R1 has a history of falls and has a fall prevention plan which includes encouraging R1 to sit in their favorite recliner in the common area where they can be frequently checked on by staff. LPA interviewed the three staff who were present during the incident who confirmed that R1 was a known fall risk, staff know to check on R1 frequently, that the fall prevention plan for R1 included encouraging R1 to sit in their favorite couch in the common area close to staff and frequent checks. The information obtained did not corroborate that R1’s fall was caused by lack of care and supervision as the second-floor memory care was fully staffed and R1 was in the line of sight of one of the staff who saw R1 fall but was unable to catch R1 in time. CONTINUED Per the facility’s medication technician supervisor, R1 had a change of condition relating to a urinary tract infection before the fall on April 20, 2025, facility staff communicated almost daily with R1’s doctor regarding R1’s condition, R1’s condition got worse days after their fall due to their urinary tract infection which resulted in their hospitalization on April 23, 2025 and return to the facility on hospice on April 30, 2025. LPA reviewed R1’s medical records dated April 30, 2025, which indicate that R1’s fall did not result in any serious injuries, R1 had an acute urinary tract infection and electrolyte imbalances due to dehydration, R1 refused to eat at the hospital, R1’s family discussed the possibility of hospice, and R1 was discharged back to the facility on hospice. LPA reviewed R1’s progress notes which document that facility staff noticed R1’s change of condition and suspected a urinary tract infection as early as April 14, 2025, and coordinated with R1’s doctor almost daily to ensure R1’s medical needs were met. LPA interviewed R1’s family who had no concerns about the care R1 received at the facility. The information obtained did not corroborate that R1’s fall led to their decline and placement on hospice or that the facility failed to meet R1’s medical needs. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.