complaint·November 15, 2021

Interviews with residents (R2, R3, R4) and staff members (S1, S2, S3, S4) indicated that there have been no witnessed instances of staff being rough with residents while receiving care. Review of documentation from hospice care and interview with hospice representative indicated that no unexplained injuries occurred while resident (R1) was receiving care at the facility. Staff care notes from the facility match care notes from hospice services. Allegation: Resident has sustained multiple unwitnessed falls while in care. Interviews with R2, R3, R4, S2, S3, S4, and relevant parties indicated that there have not been any witnessed or unwitnessed instances of a resident falling while at the facility. Interviews with R2, R3, R4, S2, S3, S4, and relevant parties also indicate that there have not been any witnessed or unwitnessed instances of R1 falling while living at the facility. Allegation: Facility failed to report incident(s). Documentation from hospice care and interview with hospice representative indicates that there have not been any incidents regarding R1 that have not been reported to relevant parties. Hospice documentation indicates that one stage 1 decubitus ulcer sustained by R1 was reported to R1's family. Interviews with staff members S1, S2, S3, S4, and Administrator demonstrate that facility is aware of when to report an incident to Community Care Licensing. Based on interviews conducted by LPA, observations during inspection, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.