Complaint·March 18, 2022

Per review of R1's care plan, and per interviews with staff, R1 was a fall risk, and was on a fall risk care plan but R1 was not on a one to one care staff need. R1 was assessed by facility staff to be a fall risk due to medical documentation and personal history obtained from the Power of Attorney (POA). R1 was supervised, and care needs met, per staff interviews, and LPA's interview with other party(s) related to the investigation. Per LPA's file review, upon R1's admittance into the facility, there is documentation identifying R1 as a fall risk, and information provided regarding falls/falling stating that there is no way to ensure a fall never happens but to ensure a general level of supervision to residents, and that staff will strive to keep a resident from falling, and that even with total supervision of a resident, this may not prevent a resident from falling, This document is signed by the POA of the resident. Per interview with (S1 and S2) R1 had a fall on 2/12/22 as R1 had left the dining room , and walked into the center hallway. Staff (2)RN who was doing paperwork in the dining area heard R1 fall, and rushed out to assess R1, other staff assisted as needed. Staff assessed R1 as having hit their head which resulted in an injury, and contacted 911 immediately; 911 was contacted due to the resident's sustained head injury, and medication the resident was on. Per interview with staff, the 911 emergency medical services (EMS) arrived quickly, and medical attention for R1 was obtained about 10 minutes after the incident occurred. There was differing information obtained from reporting party regarding the allegation. There was no obtained information by the LPA to support the allegation, Lack of supervision resulting in resident injury and possible death. Based on LPAs observations, record reviews, interviews with staff, interviews with other party(s), and conflicting information obtained from other related party(s), there is insufficient information to prove or disprove the allegation of Lack of supervision resulting in resident injury and possible death. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations/deficiencies. Exit interview conducted with John Wotring, Administrator. Per interview with staff, the 911 emergency medical services (EMS) arrived quickly, and medical attention for R1 was obtained about 10 minutes after the incident occurred. Per interviews, and file reviews, the resident went out 911, on 2/12/22, after having a fall that resulted in a head injury. There was differing information obtained from reporting party regarding the allegation. There was no obtained information by the LPA to support the allegation per the investigation by the LPA. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation, Facility failed to seek timely medical attention , is Unfounded. We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No citations/deficiencies. Exit interview conducted with John Wotring, Administrator.