complaint·January 10, 2022

Resident was injured while in care. On 12/16/2021, LPA spoke with Resident #1 (R1) regarding injuries while in care. Based on interview, R1 attempted to lower bed and the table tilted over. R1 stated, she almost fell out of the bed. R1 stated she twisted her arm and back. Based on interview, Staff #3 (S3) and Staff #4 (S4) stated R1's table had fallen and S3 picked it back up. S3 stated she did not observe any injuries. Based on Staff #1 (S1), R1 moved out of the facility on 12/20/2021. LPA is unable to prove or disapprove if allegation occurred. Staff did not respond to resident's calls for assistance. On 01/10/2022, 3 of 4 residents stated they use there pendants. 3 of 4 residents stated when their pendants are pressed, staff respond in a timely manner. 4 of 4 staff stated residents pendants are always answered. LPA collected and reviewed pendant history for R1. Based on documentation, R1 had a history of pressing the pendant throughout the day. On 01/10/2022, LPA observed the pendant was cleared when R1 pressed the pendant on 12/18/2021 through 12/20/2021. However, 1 of 4 residents stated staff did not respond to resident's call. LPA is unable to review all pendant history for the month of December due to the system saving information for only 30 days. Based on interview, R1 moved out on 12/20/2021. Facility staff did not ensure that diabetic resident was fed timely. On 01/10/2022, LPA collected and reviewed R1's room service slips dated 12/01/2021 to 12/11/2021. Based on documentation, R1 was fed for breakfast, lunch, and dinner daily. Based on resident interviews, 3 of 4 residents stated facility staff ensures residents are fed timely. Based on staff interviews, 4 of 4 staff stated all residents are fed in a timely manner. However, 1 of 4 residents stated staff does not feed resident in a timely manner. Based on S1's interview, the room service slips are not used everyday. The room service slips are used for charging purposes, not tracking. LPA was unable to verify the remaining times R1 received her food. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted with Executive Director and a copy of report given.