complaint·August 31, 2022

It was revealed through staff interviews that there was (1) caregiver in R1’s cottage when R1 had a fall in their restroom. Staff interview revealed R1 was too heavy to assist off the floor, so they called and waited for another caregiver to assist them from a neighboring cottage. Staff interviews revealed the facility mitigated R1’s fall through a call button necklace which R1 would remove off their person and “forget” to press for assistance. No additional methods of fall mitigation were revealed at the time of the visit. Therefore, based on this information the facility did not take the precautions necessary to prevent this fall. The allegation is substantiated. Concerning allegation #2 "Facility does not have adequate staffing to meet resident's needs". Staff interviews revealing that there was (1) caregiver in R1’s cottage when they fell in their restroom. Staff interviews revealed they needed to call another caregiver to assist R1 off the floor from a neighboring cottage. Records review of R1’s Needs and Services Plan revealed R1 required total assistance for most care needs. Therefore, the facility was not adequately staffed. Therefore, the allegation is substantiated. Concerning Allegation #3 "Resident's hygiene needs are not being met". It was alleged R1 was not assisted to the restroom when they fell at the facility. Staff interviews revealed R1 had a fall in their private restroom when attempting to relieve themselves and fell. Staff interviews revealed (1) staff was present in R1’s cottage at the time of the fall and arrived to assist R1 when they were already on the floor. Staff revealed they needed to call another caregiver to assist R1 off the floor. R1’s Needs and Services Plan revealed they required a (1) person total assist when toileting. Therefore, based the allegation is substantiated. Findings that are substantiated mean the preponderance of the evidence standard has been met. Deficiencies were cited on an LIC9099-D page. An exit interview was conducted where a copy of this report along with LIC9099-D pages, as well as appeal rights were provided to Executive Director, Cristina Miller.