complaint·March 10, 2025

After 9/5/2024, R1 was noted to be combative again, with aggressive behaviors and sustained un-witnessed falls, where they were sent to Emergency Department (ER) and returned the same day with a change in medications. Facility expressed that R1 was in the facility for a short period of time, the first week is always hard for new residents to adjust to their new home. R1 continued to be combative was sent to ER and the medication was adjusted, R1 was then more sleepy, and sustained falls in their room while walking and not when assistance or supervision was required by staff, based on their service plan. on 9/10/2024, R1 was placed on Hospice care with Anchor Health, who placed R1 on comfort meds ordered and increased medication. Facility was following R1s doctors and Hospice orders with medication and medication was keeping resident sleepy. Facility stated they had developed a fall prevention plan as R1s was often drowsy from the medication, and a meeting with R1s family and Physician was being planned, but R1 moved out on 9/18/2024. Staff interviewed expressed R1 was being supervised and did not require 1 to 1 care. Although the allegations may be true, based on the above information, and records reviewed, there is not a preponderance of evidence to prove or, disprove, the allegation did occur. Therefore, the allegation for s taff did not provide adequate supervision to resident in care resulting in multiple falls is UNSUBSTANTIATED at this time. No citation issued.