Complaint·December 16, 2024

LPA Monter interviewed ADM. ADM stated the facility provided To go boxes and disposable containers with food, for covid positive residents. ADM stated All staff were wearing masks and automated machines were in the 2nd and third floor. ADM stated Housekeeping, had disinfectant sprays as well. ADM stated they tested the whole community and staff. ADM stated covid positive staff were isolated. ADM stated they Contact family and contact their doctors. ADM stated they Test residents every 3 days. LPA Monter interviewed residents R2-R9. 1 Out of 9 residents (R2) stated he/she doesn’t know what the facility did during a covid outbreak at the facility. 2 Out of 9 residents (R4, R7) stated they did not want to be interviewed. 5 Out of 9 residents (R3, R5, R6, R8, R9) stated they observed staff wearing masks during a covid outbreak. On October 22 & November 12, 2024, LPA Monter interviewed staff S5 and S6. S5 stated the facility provided mask and hand sanitizer. S5 stated staff were masks during an outbreak. S6 stated he/she isn’t comfortable answering the question and stated she does not want to answer. Based on a review of the facility’s infection control plan dated May 2022, the facility shall follow their county’s department of health instructions. The Policy also states staff will wear masks during the virus season/ viral outbreak. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 2 Out of 2. END OF REPORT. On October 22, 2024, LPA Monter interviewed Staff S5. S5 stated he/she was working the night shift when R1 had fallen on August 13, 2024. S5 stated he/she and S6 were assisting a resident on the third floor, who needed assistance. S5 stated later that night R1's family member came to the facility and informed S5 and S6 that R1 had been on the floor for hours. S5 stated he/she ran upstairs to check on R1 and assisted him/her up. On November 12, 2024, LPA Monter interviewed staff S6. S6 stated he/she was working the night shift when R1 had fallen on August 13, 2024. S6 stated he/she could not provide any details on what had occurred that night. S6 confirmed that R1 has the behavior of getting up at night 3-4 times at night. Based on a review of R1’s care plan dated March 18, 2024. states R1 is a moderate fall risk- meaning R1 requires direct interventions that are customized to the identified risk factors. The care plan also states R1 needs standby assist with transferring, and R1 uses a walker to ambulate and has an occasional disturbed sleep pattern. This form states R1 requires status checks every 2 hours at night. Based on a review of R1’s Physicians Report, dated September 20, 2023, R1 has a neurocognitive disorder. R1 is also a risk for falls if unattended. Based on a review of evidenced provided, R1 was last seen by facility staff on August 12, 2024, at 11:21pm. Resident R1 fell on the floor, in his/her bedroom, on August 13, 2024, at 12:19am. Facility staff returned to R1’s bedroom and picked R1 up on August 13, 2024, at 3:47am. The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. This report was reviewed with Health & Wellness Director Dominique Frommo. A copy of the report & appeal rights were provided.