complaint·April 19, 2025

The investigation revealed the following: regarding the allegation- Facility staff dropped resident during a transfer resulting in bruising- It is alleged S6 dropped R1 while transporting them from their wheelchair to their bed. Five (5) out of the five (5) staff interviewed denied this allegation. Staff interviews revealed R1 had been agitated earlier that morning and staff administered a PRN to calm R1 down. Records reviewed revealed staff documented R1 was still agitated after PRN and R1’s doctor was notified. Staff interviews revealed R1 made a sudden movement forward in their wheelchair and fell out right as S6 was attempting to transfer R1 to their bed. Staff interviews did not corroborate S6 dropped R1 while transferring R1 to their bed. Eight (8) out of eight (8) residents interviewed denied this allegation. Review of hospice notes dated 9/30/2023, revealed hospice staff provided care to R1 because of a fall. Review of S6’s personnel record did not corroborate this allegation. LPA Ramirez attempted to interview R1, but R1 is no longer at the facility and unavailable for interview. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Facility did not notify resident's family of incident- It is alleged facility staff did not notify R1’s family when she had a witnessed fall. Five (5) out of the five (5) staff interviewed denied this allegation. Eight (8) out of eight (8) residents interviewed denied this allegation. Records reviewed revealed staff documented R1’s fall to R1’s Power of Attorney (POA), doctor and hospice were all notified on 9/30/2023. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Facility did not seek timely medical attention for resident- It is alleged facility staff did not seek timely medical attention for R1 after a witnessed fall sustained on 09/30/2023. Five (5) out of the five (5) staff interviewed denied this allegation. Eight (8) out of eight (8) residents interviewed denied this allegation. LPA Ramirez attempted to interview R1, but R1 is no longer at the facility and unavailable for interview. Records reviewed revealed on 9/30/2023, hospice arrived after 2pm to assess R1 due to fall. Hospice notes revealed R1 was assessed and R1’s family requested to not send R1 to the hospital but wanted to keep R1 comfortable and pain free. Hospice notes and facility staff notes documented R1 had bruising to their head, left side and hand. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Staff did not dispense medication according to doctor’s orders- It is alleged facility staff did not administer pain medication to R1 after witnessed fall on 09/30/2023. Five (5) out of the five (5) staff interviewed denied this allegation. Eight (8) out of eight (8) residents interviewed denied this allegation. LPA Ramirez attempted to interview R1, but R1 is no longer at the facility and unavailable for interview. Records reviewed revealed R1 had a medication order for PRN prescription for pain. Records reviewed revealed on 9/30/2023, hospice staff administered pain medication to R1 on 09/30/2023 due to a witnessed fall. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies were issued for this complaint investigation. Exit interview was conducted. A copy of this report was provided.