Complaint·March 28, 2025

(continued form 9099) According to R1’s LIC602 Physician’s Report, R1 was diagnosed with a cerebral infarction affecting the left non-dominant side as well as dementia.  The admissions agreement, as well as the Hospital Discharge documents, indicate R1 has a history of falling. Interviews with staff indicate R1 prefers the left knee to be bent and leaned over against a solid surface. During today's visit, LPA Rodgers observed full bed rails on R1's bed.  LPA observed four other residents beds with no full bed rails.  Interviews and records review revealed that 1 of 5 residents are on hospice and 1 hospice resident (R1) has an physicians orders for full bed rails with a care plan dated 3/19/2025.  Interviews and LPA observations revealed that R1  is capable of moving around in bed but prefers lying down with his left leg pressed up against a solid surface.  Interviews revealed that the full bed rails are used to prevent the residents from falling during the day and night when R1 is sleeping. Interviews with staff reveal staff they picked up R1's bed from R1's previous  facility and used the bed from 3/3/2025 to 3/18/2025.   Interviews with outside source and staff conflict as to whether R1 had full bed rails from 3/3/2025 to 3/18/2025. However,  LPA observed R1 old bed stored in the garage.  The bed stored in the garage did not have full bed rails and Interviews with staff describe that was the bed R1 was using from 3/3/2025 to 3/18/2025. Int erviews with staff and other Resident #2(R2), R1 roommate, do not describe behaviors that would lead R1 to attempting to leave the bed unattended.  Staff #1 describes behaviors when trying to attend to incontinence needs for R1 but no other time. The hospital transfer document(dated 3/5/2025) and the Physician's report do not indicate behaviors that would lead R1 to trying to get out of bed unattended. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Todd Brooks and the care giver George Bajara. A copy of this report was provided and their signature on this report confirms receipt.