complaint·January 24, 2025

It was alleged that R1 had three falls since July 2024, R1 is often left alone at the facility, and staff ignore R1’s toileting needs. LPAs inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPAs inspected R1’s room, noted R1 is not currently present at the facility, and observed a hospital bed with a half bedrail, a fall mat, and a walker in R1’s room. LPAs interviewed AD who stated R1 moved in on June 6, 2024, and was noted as a fall risk. LPAs reviewed R1’s Skilled Nursing Facility Discharge Paperwork dated June 6, 2024, which states R1 has a history of falls and fractures, and requires assistance with mobility, transfers, and toileting. LPAs reviewed R1’s Orientation/In-Service Training dated June 7, 2024, which indicates the facility had a fall prevention plan and staff were trained on how to meet R1’s needs. However, despite the fall prevention plan, per AD, shortly after moving in, R1 had their first fall. LPAs reviewed a facility incident report dated June 10, 2024, which states R1 had an unwitnessed fall on June 7, 2024, which resulted in a wrist sprain. After this fall, R1’s fall prevention plan was updated. LPAs reviewed R1’s Preplacement Appraisal dated June 6, 2024, R1’s Appraisal dated June 6, 2024, and R1’s Appraisal/Needs and Services Plan dated June 6, 2024, which document R1’s fall prevention plan was updated to include a hospital bed with half bed rails, bed alarms, a walker, and checks every 15 minutes. Per AD, after these fall prevention precautions were put in place, R1 did not have another fall until October 5, 2024. LPAs reviewed a facility incident report dated October 5, 2024, which states that on October 5, 2024, R1 was found on the floor and taken to the hospital. Per AD, R1 was diagnosed with a hip fracture as a result of this fall, was treated at a hospital, and continued treatment at a skilled nursing facility until January 17, 2025. Per AD, R1 was brought back to the facility on January 18, 2025, with updated fall precautions. LPAs reviewed R1’s Preplacement Appraisal dated January 18, 2025, and R1’s Appraisal/Needs and Services Plan dated January 18, 2025, which document that R1’s fall prevention plan was updated to include bed-to-chair standby assist. However, per AD, R1 had another fall shortly after returning to the facility. LPAs reviewed a facility incident report dated January 20, 2025, which states that R1 had a witnessed and assisted fall on January 19, 2025 and sent to the hospital. Per AD, R1 was released from the hospital, is not currently at the facility, and the facility will reassess whether it can meet R1’s needs. Per AD and staff interviews, memory care residents are checked on every 15 minutes. LPAs reviewed the facility’s Memory Care Headcount Logs which corroborate that memory care residents are checked on every 15 minutes. Per witness interviews, there are no concerns regarding the fall prevention plan put in place by the facility. LPAs interviewed AD and three staff who denied that R1 was left alone or that R1’s toileting needs were ignored. LPAs interviewed one witness who did not corroborate the allegation. LPAs interviewed seven residents who did not corroborate the allegation. Although R1 had falls on June 7, 2024, and October 5, 2024, the facility had a proper fall prevention plan in place which it updated in response to R1’s falls in order to address R1’s fall risk and the fall on January 19, 2025, was witnessed and assisted, which means it could not have been prevented by the fall prevention plan. The information obtained did not corroborate the allegation. 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.