Complaint·March 21, 2024

Interview with staff confirmed safety checks were performed for R1 throughout the day and night. There is no clear indication that the facility was not providing proper care and supervision during the time of each unwitnessed falls. Therefore based on interviews and record review, the allegation “Staff’s lack of supervision resulted in resident sustaining multiple falls and hospitalization” has been deemed unsubstantiated at this time. Regarding the allegation “Staff left resident soiled on the floor” it was reported R1 was left on the floor soiled and does not receive amble care. Interview with R1’s responsible party revealed during the unwitnessed fall on 01/04/2024, R1 had soiled himself and the caregivers who were present during the fall did not assist R1 with cleaning R1 up. Interview with staff revealed most of R1’s falls occurred while ambulating to the bathroom. Staff would observe if R1 had soiled themselves and would assist with changing and cleaning R1 or R1 would request assistance from staff to help clean up. Facility staff notes for R1’s falls do not notate if resident had soiled themselves during the fall. Record review of R1’s file reveals R1 maintains independence and does not require assistance for toileting. R1 requires staff assistance for personal hygiene. Therefore based on the information obtained, there is not enough evidence that staff left resident soiled on the floor. Therefore, the allegation has been deemed unsubstantiated at this time. Although the allegation(s) 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(s) are UNSUBSTANTIATED. An exit interview was conducted where a copy of this report was discussed and provided to Executive Director Hill.