complaint·August 28, 2025

(Continued from LIC 9099) The Physician's Report dated 1/17/2025 states R1 has a diagnosis of dementia. Upon questioning, R1 could not recall a recent fall that occurred. R1 stated they enjoyed their breakfast but could not recall what they ate for breakfast. LPA interviewed two of two witnesses, four of four staff and Resident #1 (R1) regarding the fall incident. Two of four staff members were present at the time of the fall. One staff member witnessed R1 sitting on the bed and then R1 losing their balance and falling to the floor. The other staff member heard the fall and headed to the area and the nurse immediately followed. LPA reviewed video footage and obtained photos of time stamps regarding the incident. Staff interviews indicated R1 had a witnessed fall at 7:42am. Camera footage shows staff member stepping out of the room and within a minute's time, a second staff member and then the nurse are observed going into the room. Staff notified Responsible Party (RP) and paramedics were on-site by 7:57am. LPA reviewed the documents and an updated assessment was conducted on August 13, 2025 regarding R1. An Unusual Incident Report was filed with the Department by the facility and resident returned on same day. Upon return, a personal 1:1 caregiver was provided to observe R1 from 8pm to 8am and Behavioral mapping of nighttime activities was completed. Based upon LPA observations, interviews, records and video review the allegation that a Resident fell due to lack of care and supervision is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Ashiman Gill, Administrator, and a copy of this report was provided to the facility. ****THIS IS AN AMENDED REPORT****