Complaint·June 25, 2021

The Department reviewed charting notes, alarm logs, and resident interim service plans. Charting notes documented that R1 had four unwitnessed falls and five witnessed falls. The alarm logs documented that the alarm was triggered on all unwitnessed falls in July 2020. Charting notes also documented R1’s most recent fall that occurred on 09/10/2020, two facility staff were present, and assisted R1 to the floor and called for help. R1 was reappraised on the following dates 07/08/2020, 07/17/2020, 07/19/2020, 07/23/2020, 07/26/2020, and 08/09/2020 for witnessed and unwitnessed falls. The Department has investigated the above allegations, and based on interviews and record reviews, the Department has determined that the allegations were Unfounded, meaning that the allegations were false, could not have happened and/or are without reasonable basis. This report was review with Steven Silacci Executive Director and a copy of this report provided. Page 2 of 2 On 6/16/2021 witness stated the facility conducted an internal investigation regarding a fall incident and left a voicemail regarding the result of the internal investigation. Between 06/18/2021-06/21/2021 a total of three family members were interviewed. 3 out of 3 family members stated they have no concern with staffing at the facility and are in daily communication with staff regarding their family member's condition. On 09/30/2020 a virtual tour of the facility was conducted. On the first floor LPA observed 4 caregivers and 1 Med Tech and on the second floor LPA observed 3 caregivers and 1 Med Tech. Residents were observed engaged in activities and groomed. Staffing schedule for the month of September 2020 was reviewed. A total of 4-8 caregivers and 2 Med Techs are scheduled to work the AM and PM shift and 4 caregivers and 1 Med Tech were scheduled to work the NOC shift. Training transcript for 2017-2020 was reviewed. Staff training shows the staff are trained in the following areas: Alzheimer's Disease and Related Disorders: Medical Care, ADL Care of the Cognitively Impaired, Alzheimer's Disease and Related Disorders: Psychosocial Care, Alzheimer's Disease and Related Disorders: Behavior and ADL Management, Preventing Slips, Trips and Falls, Understanding Falls. This Department has investigated the above allegations, and based on interviews, records review, and observation the Department has determined that the allegations were Unsubstantiated, meaning that 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. This report was review with Steven Silacci Executive Director and a copy of this report provided. Page 2 of 2