Complaint·March 27, 2025

(Continued from LIC9099 p.1) Staff interviews further revealed that R1 slipped from their bed the evening of 06/28/2024 with no injuries, and staff responded to assist them during the event. An outside advocacy agency familiar with the facility and R1's care was contacted and stated they had no concerns regarding the facility's supervision and care to residents. The outside source remarked that R1 may have been experiencing confusion when they made the statement about lying on the ground. A second outside source informed that R1 presented as independent. Records review revealed facility pendant and Narrative Charting logs during the timeframe of complaint. The documents showed that R1 pressed their pendant twice during the early morning on 06/28/24, and was responded to within 7 minutes, and then 2 minutes. The 2-minute response time was noted to be when R1 was found sitting on their bedroom floor after slipping from their bed; R1 informed staff that they did not suffer an injury during this incident. Additional facility and outside source records showed that R1 was evaluated to be independent upon moving into the facility and was able to perform all Activities of Daily Living (ADLs) without assistance, including going for walks outside of the facility unassisted. No records were found to establish that R1 required routine nighttime checks, or that staff delayed in responding to R1's pendant call when they requested help. During an unannounced facility visit LPA interviewed R1. LPA noted that R1 had moved from the Assisted Living section of the building to the Memory Care unit. R1 stated that they did not recall falling and lying on the ground all night without assistance. R1 stated that staff came right away when they pushed their call button and provided great care. R1 informed they loved living at the facility and had no issues with the care provided. 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 Executive Director Rob Daynes, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.