complaint·August 5, 2025

On the allegation: Staff did not prevent a resident from sustaining multiple falls. It was alleged that R1 had a fall on 06/27/25 in which R1 hurt their knee, alleged that within twelve hours of the first fall the resident got up to use the bathroom and fell and hit [their] head and was transported to the hospital. Reporting party stated that R1 lost 2 pints of blood. Records indicate there were 3 incidents, all unwitnessed, all occurred in residents’ room within a 24-hour timeframe, 2 on 6/27/25 and 1 on 6/28/25. On 6/27/25 R1 was found at approximately 7:00 am by medication aid during medication pass, R1 was on the floor in their room. Records state and staff interviews confirmed staff assessed R1 for injuries, initially R1 verbalized no pain or injury, staff got R1 off the floor and immediately observed R1 limping and facility contacted 911, per interview with Wellness Director (WD) first responders assessed R1 and spoke with R1 and R1’s family member (F1). Medical transport was refused after the conversation, and additional medical treatment was not sought by the request of R1 and F1. Records show that at 9:55 am R1 was given a prescription PRN Tramadol for pain. Facility records show NP was notified of incident at 1:06 pm via fax. Facility submitted an incident report to Community Care Licensing (CCL). On 6/27/25 at approximately 1:45 pm staff heard R1 yelling for help, R1 told staff and records state that R1 was trying to open their door and fell. Physical Therapy referral requested. WD stated the fall was due to R1 not having shoes on. R1 was assessed, no injuries present. Facility records show NP was notified of the incident at 11:25 pm via fax. On 6/28/25 R1 was found during the medication pass at approximately 5:30 am. Interviews and records state medication aid walked in and observed R1 on the floor and noted a “head injury and resident near [their] bed on the floor.” Facility called 911 and stayed by R1. Records state, “resident unable to give description” of what had happened and that “Resident appeared disoriented.” The incident resulted in unknown head injury, with blood loss. Review of R1 medication records shows they were on a blood thinner. During record review, LPA noted that physician’s order dated 6/2/25 and 6/16/25 for PRN Tramadol stated, “1 tablet orally at bedtime as needed for pain”. During an interview LPA was told that medication was given the morning after the incident and Medication Administration Record (MAR) showed R1 took a PRN tramadol at 9:55 am on 6/27/25. Interview at 3:20 pm on 7/25/25 with NP, LPA inquired why PRN was ordered for “bedtime”. NP stated prescribed “at night, in case the resident gets tired from the medication, and so they don't fall." Continue on 9099-C Record reviewed do not show history of falls, pre-assessment documented by F1 states R1 had a mini stroke in March, but “has not fallen…” Interviews with staff for incidents on 6/27/25 state that R1 was at their normal baseline following both incidents. Staff state R1 is usually a little confused and needs prompting. Record review indicates that the care level assessment and Service Plan Report effective date 4/21/25 for R1 shows that R1 requires cueing throughout the day for orientation, escort and cueing for; meals, activities, moving throughout the facility, that R1 requires frequent checks for toileting, brief changes, medications, reminders for daily activities, transfers in and out of bed, bathing, and grooming in the morning and bedtime. R1 does not have a history of falls prior to entering the facility and has not had falls until the 3 incidents noted above which occurred in a short time frame. Facility followed their protocols, requested emergency services, notified a medical professional, requested PT after a second incident. Based on record review and staff interviews at this time the above allegation was found to be unsubstantiated, there is not a preponderance of the evidence to prove that the alleged violation occurred. On the allegation: Staff administered a medication that was not prescribed to a resident in care. It was alleged medication provided to R1 on 6/27/25 did not belong to the R1. The documented order dated 6/2/25 and renewed order on 6/17/25 was provided to the LPA upon request, both were signed by the NP and confirmed during interview with NP on 7/25/25. Medication was prescribed, but given at 9:55 am which is not following doctor’s order of “1 tablet orally at bedtime as needed for pain.” LPA conducted a Case Management addressing this medication error. Based on record review and interviews conducted, at this time the above allegation was found to be unsubstantiated, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Copy of report provided to facility.