complaint·December 15, 2022

LPA interviewed R1’s responsible party who stated that R1 falls quite often and requires transferring from her bed to her wheelchair all the time. R1’s responsible party stated that R1 always had a lot of bruises and was declining quickly. R1 was placed on hospice care on December 2021 due to the rapid decline in health. Also, resident was receiving physical therapy twice a week upon admission for balance and being a fall risk. S1 who reported that three staff members lifted when R1 fell on October 27, 2021. S1 stated that resident was found between 6:30 AM and 7:00 AM with her back facing up. The Administrator stated that the final check that morning was between 5:20 AM and 5:45 AM. S1 stated that R1 is checked every two hours for safety checks. S1 also added that all staff are trained to properly transfer residents. S2, Medication Technician, stated that she dialed 911 emergency personnel immediately after she came to R1’s room and saw her on the floor. R1’s first fall was on October 27, 2021 and was returned to the facility the same day. R1 was returned to the community with a Urinary Tract Infection and was prescribed antibiotics. S3 who is the former, Wellness Director/LVN stated that resident was reported by staff to have their leg hanging off the bed often. R1 who has dementia also takes off their diapers often and feces might have gotten into their nails. S3 reported that the hoyer lift was delivered to the facility on 10/13/2021. S3 also stated that 911 emergency personnel was called for R1 for shortness of breath on October 12, 2021 and October 22, 2021. Based on the information gathered during the investigation and review of all documents obtained, the following allegations: Staff caused bruising to resident, Staff are not properly transferring resident, Resident was left on the floor for an extended period of time, resident was left in soiled clothing for an extended period of time, staff did not seek or address residents medical condition in a timely manner are deemed Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted and a copy of this report was provided during the visit to Terrie Sherrell, Assisted Living Director.