Complaint·November 3, 2022

Licensing Program Analyst (LPA’S) Kesha Lewis and Albert Johnson conducted an unannounced facility visit on 11/03/2022 to deliver complaint investigation findings. LPA’S met with Administrator Mary Keaton and explained the purpose of today's visit. The purpose of the visit is to deliver complaint investigation findings from an incident reported to the department received on 08/22/2022. Based upon documentation reviewed LPA’s observed multiple unwitnessed falls documented on internal documentation 6/30/2022, 7/5/2022, 7/6/2022, 7/19/2022,7/20/2022,7/22/2022. Interviews conducted with administrator and director of resident services they conformed that they do not send incident reports for falls unless resident is sent out to emergency room. R1’s Physician’s report states the resident has a history of falls. Based on records reviews and interviews LPA’S found inconsistencies with facilities incident reports and the department having no record of reports for those dates. Therefore, the second allegation the Facility does not report incidents Is substantiated. A finding that the complaint is substantiated means the preponderance of evidence standard has been met, therefore the allegation(s) is found to be substantiated. Exit interview conducted and copy of report provided. Appeal rights given.