Complaint Investigation Report

S1-S3 stated the Med Techs are alerted if the residents call light system beep on the system, it will show what room needs help. R1's roommate would have heard R1 calling staff for assistance.

Executive Director (ED) Terri Weitzman stated that R1 is the hoarder and she fell on her side of the room. R1 was interviewed and stated it was not the staff's fault that she had fallen and she was not sure of the time or how long she was on the floor. R2 the roommate was interviewed and stated she gets up around 3:00 A.M. - 3:30 A.M., to go to the bathroom every morning. R2 stated that R1 was not on the floor at that time. R2 stated she did not hear anything and she was still sleeping when the caregiver Maria Garcia came inside the room. Caregiver Maria was interviewed and stated she walked past that room all night long and did not hear anything, there was no sound, noise, motion, or movement coming from room 222. Caregiver Maria stated that R1 and R2 are super independent and don't want staff assisting them with anything. Maria stated she found R1 on the floor that morning, and she called Med Supervisor Chanel Lee for assistance. R1 stated she was fine and did need any medical treatment.

Allegation #2 Facility does not provide a safe environment for the resident.

Staff 1-3 (1-3) and residents 1-11 (R2-R11) stated the facility does provide a safe environment for residents. R1-R11 stated they were happy living here. S1-S3 and R1-R11 stated staff checks on residents throughout the morning, day, evening, and night. S1-S3 stated residents are given a comfortable living environment and the facility provides a safe environment for all residents in care. S1-S3 and R1- R11 stated staff is providing the care and supervision necessary to meet the resident's needs.

Investigation revealed the following: Staff 1-3 (S1-S3) and residents 1-11 (R1-R11) interviewed all agreed the facility has 24-hour care and awake staff walks the hall and is always doing room checks in the middle of the night and early morning. Staff would have heard R1 if she called out for help. Ms. Weitzman stated on 05/20/2022 Resident 1 (R1) was found on the floor by the Caregiver Maria Garcia and she immediately called the Medication Supervisor Chanel Lee for assistance. Med Supervisor Chanel Lee went to room 222 to assess R1. R1 was interviewed and stated she tripped on her rug and fell on her way to the bathroom. R1 stated she doesn't know how long she was on the floor and couldn't reach the call cord to ask for help. S1-S3 stated R1 is independent they had no control over R1 falling on the floor and couldn't have prevented R1 from falling on the floor. Staff was not present during the fall. See continued LIC812-C page 3