complaint·March 12, 2024

(Continued from LIC9099 p.1) Outside source interviews corroborated staff statements that paramedics responded to the facility numerous times due to R1's falls, and that R1 frequently refused to be transported to the hospital. Outside sources informed that R1's family and Responsible Party were notified regarding the falls, and were involved in the conversation regarding R1 needing an increased level of care. Facility and outside source records review revealed that R1 suffered multiple falls due to attempting to ambulate on their own, even after staff reminded them to use their pendant to call for help before trying to walk. Facility incident reports, email communication, and progress notes showed that the Licensee was monitoring R1's change in condition, reassessed R1, and communicated the changes to the Responsible Party. Records review further showed that R1 was placed on Hospice per the family's request, and the Licensee assisted with the transition into Hospice care. Interview with R1 was not possible, due to their passing away. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Senior Regional VP of Operations Steven Harms, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.