Complaint Investigation Report

The allegation of “Staff did not ensure residents signal alert system was implemented as part of their care plan.” alleges that facility staff did not implement appropriate fall prevention measures including a fall detection mat as part of Resident #1 (R1)’s care plan. LPA conducted a file review for R1 and observed that R1 was identified as a level three (3) fall risk which indicated that R1 had the potential for falls to occur. LPA did not observe a fall detection mat listed in R1’s plan of care. LPA interviewed Witness #1 (W1) who stated that R1 suffered three (3) falls at the facility in a short amount of time between late December 2025 – January 2026. W1 stated that a fall detection mat was purchased for R1 but was not utilized by the facility. LPA interviewed the Executive Director Grace Hartnett (ED), who stated that they had a meeting with R1’s family to discourage the use of the fall detection pad. ED stated that some other memory care residents had similar mats in the past, but all have since been removed. ED stated that the mat is a commercial device that was provided and since the device is not an approved by the facility the responsible party of R1 was responsible for the maintenance of the device. ED stated that they spoke with R1’s responsible party and they agreed to remove the mat. ED stated that they have since implemented a lower bed and a soft mat which is placed at the side of the bed while R1 is sleeping to assist in mitigating R1’s fall risk. ED stated that the facility monitors the apartment for clutter and removes any fall risks throughout the day. ED stated that the resident is on frequent checks each hour and staff are notified via set alarms on their phones. LPA interviewed two (2) staff members who assisted in providing care to R1. The staff members interviewed confirmed that R1 had been placed on frequent 30-minute checks and that additional fall prevention measures including a lower bed and soft mat had been implemented to mitigate R1’s falls. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not ensure residents signal alert system was implemented as part of their care plan.” Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of “Staff do not ensure care and supervision is being provided to resident.” alleges that facility staff do not ensure adequate supervision because R1 suffered three (3) falls in a short timeframe, staff do not check on R1 regularly, and that facility staff do not assist R1 with utilizing the bathroom. LPA observed R1’s resident file and observed that R1 was receiving assistance with incontinence care. LPA observed that R1 was assessed as requiring frequent checks due to R1 residing in the memory care unit of the facility. Additionally, LPA observed that R1 was identified as a level three (3) fall risk which indicated that R1 had the potential for falls to occur.