complaint·May 20, 2025

Therefore, based on the evidence obtained during the Department's investigation, the allegation of resident died due to staff neglect is UNSUBSTANTIATED at this time. Although the allegation resident died due to staff neglect 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 at this time. An exit interview was conducted where this report (LIC9099), was discussed and provided to Assistant Administrator Mary Gonzalez. Medical records review dated 7/25/2023 confirmed R1 diagnosis and treatment of a fractured ankle. In addition, Department staff investigation revealed that R1 was placed in a splint and R1 physician requested skilled nursing placement on 07/28/2023. The Department staff investigation indicated that reappraisal was not required for R1 as staff at the facility reported the incident to R1's physician and requested for R1 to be seen after R1's fall. The second allegation indicates facility did not have enough staff to meet the needs of resident in care. The Department staff interview with Staff #1 (S1) confirmed that R1 needs two-person transfer. Department staff reviewed R1 Individual Service Plan (ISP) completed on 9/26/2023 for the Assisted Living Waiver Program (ALW) stating R1 has a history of falling, uses a wheelchair and needs two-person transfer. Department staff investigations revealed that on 01/17/2024, R1's call light was on and S3 had gone to R1's room alone for assistance and arrived at the doorway to enter the room and heard R1 say, "diaper change" and could see R1 already moving to a standing position from R1's wheelchair and fell to the floor. S3 reported to Department staff that S3 had no time to try to catch or grab R1. Though the Department staff investigation revealed that it was only S3 who responded to R1's call light that resulted to R1's fall as R1's assigned caregiver Staff #4 (S4) was on lunch break, there was no indication that S3 attempted to assist and transfer R1. In addition, interview with S3 indicated that the incident happened so quickly that S3 did not even have time to put rubber gloves on. Department staff investigations revealed that S3 did not attempt to assist or transfer R1 as S3 reported knowing that R1 needs two-person assist. The Department staff interview with S2 indicated that S3 called for a Medication Technician (MedTech) to help with an emergency in R1's room and asked for 911 to be called after R1's fall and S2 did not provide information that S3 attempted to assist or transfer R1. Therefore, based on the evidence obtained during the Department staff investigation, the allegation of staff did not reappraise resident as necessary (Allegation #1), and facility did not have enough staff to meet the needs of resident in care (Allegation #2) are UNSUBSTANTIATED at this time. Although the allegation staff did not reappraise resident as necessary (Allegation #1) and facility did not have enough staff to meet the needs of resident in care (Allegation #2) 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 at this time. An exit interview was conducted where this report (LIC9099) was discussed and provided to Assistant Administrator Mary Gonzalez. ***This is an amended report for the LIC9099 report issued on 05/20/2025***