complaint·June 14, 2024

(Continued...) Per Needs and Service Plan dated May 6, 2024, R1 was assessed by the facility to be a high risk for falls. R1 sustained unwitnessed falls on April 2 and April 28, 2024. Facility spoke with R1's responsible party (RP) on April 28, 2024 regarding R1's change of condition. As a result facility spoke to RP about memory care placement and removed items from the apartment that could be potentially harmful. Following discussion with RP, R1 sustained falls on April 29th, 30th and May 1, 2024. Facility sought medical attention on April 30th and May 1st. RP was notified by facility of incidents after each fall. Upon return facility retained a private caregiver to provide additional supervision for R1 on May 2, 2024. Per email from Agape Home Care to facility on May 16, 2024, Agape Home Care was notified by RP on May 6, 2024 to stop service. RP advised facility that they would make arrangements for their own private caregiver for R1. On May 7, 2024 R1 sustained an unwitnessed fall. 911 was called and R1 was transported to the hospital. Health and Wellness Director notified RP of fall and the absence of a private caregiver. RP advised they were aware and was planning to provide supervision themselves and had been en route to the facility when the fall occurred. Following the fall, RP notified facility of intent to move R1 to a higher level of care. Shortly after moving on May 8, 2024 it was reported R1 passed away. Interviews with three of three staff members confirmed they were aware of R1's fall risk and that measures had been put in place to prevent falls from occurring. Two of the three staff members stated falls could have been prevented if a private caregiver was provided. Facility progress notes show staff were monitoring R1 continuously. Based on the preponderance of evidence, the allegation that staff do not prevent a resident from sustaining multiple falls while in care is unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. No deficiencies cited during today's visit. An exit interview was conducted with Administrator Justine Ortiz and a copy of this report was provided.