complaint·November 6, 2024

CONTINUED FROM FORM LIC9099 During the present visit, LPA conducted a tour of the memory care ground level and reviewed the unit shared by R1 and another resident. Additional hospice and facility records for R1 were requested and reviewed during the visit. Regarding the allegation that Staff does not provide care and supervision resulting in multiple falls , the following has been concluded: Resident R1 has been admitted to the facility since May 30, 2023. The latest physician report for R1 is dated July 17, 2024 and shows a primary diagnosis of unspecified dementia along a secondary diagnosis of "Other abnormalities of gait and mobility". Based on interviews and incident reports reviewed, R1 sustained multiple fall incidents reported on June 11, 2023 as well as September 3, 2023, August 15, 2024, August 23, 2024 and September 9, 2024. Interviews and records reviewed also showed that R1 had been admitted to receive hospice care on August 28, 2024. Staff in-service training on fall prevention was provided on August 23, 2024. Precautionary measures such as a lowered bed with full rails, rail pads, floor pads and bed alarms have been implemented alongside a plan of care ensuring that R1 is transferred out of bed and placed either in their wheelchair or recliner in the facility's common areas. No further fall incidents have been reported since these precautions have been put in place. During the present visit, R1 was observed to be positioned in one of the recliners in the facility's common areas, as described in the hospice plan of care. As a result, the allegation is found to be Unsubstantiated, meaning that although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to a facility representative.