Complaint Investigation Report

HH notes. Each of the dates were documented by HH, who provided wound care and mental assessment and worked with facility staff to prevent falls and to observe any changes in condition. Facility also documented on Unusual Incident Reports to the Department regarding R1's falls and the medical services received.

On June 16, 2025 LPA interviewed three of three residents regarding care received. Three of three residents did not have issues with care and that staff arrived in a timely manner and would check on them throughout the day. LPA toured R1's apartment and did not observe any immediate fall risks and spoke with Resident #2 (R2) who is R1's spouse, regarding any care issues. R2 stated everything was fine.

It is alleged the: Facility staff did not address resident's fall risk. LPA interviewed two of two staff members regarding Resident #1 (R1) and both felt staff constantly checked on R1 and Resident #2 (R2) due to R2's higher level of care. Staff reported R1 had access to a pendant at all times and had frequent checks. The Responsible Party (RP) was notified of R1's falls and does not have any concerns other than the resident has falls due to becoming weaker. Both the facility and Home Health continued to monitor R1's fall risk and were in communication with the RP.

It was alleged the Facility staff did not address resident's change in condition. Unusual Incident Reports and Home Health notes both documented that if R1 had any systemic infections; facility and home health were to follow-up with physician if any changes of condition were observed. Both facility and HH continued to monitor R1's falls and assess R1. Home Health notes on March 10, 2025 documented R1, who was initially independent, was no longer able to leave the community and that facility staff and RP were informed. Two of two staff reported R1 continued to have frequent checks and that R1 would not press pendant for assistance. On May 24, 2025 R1 was sent for further evaluation after a fall and returned to the community with no new orders. R1 fell on June 4, 2025 and was admitted at the hospital and Skilled Nursing for rehabilitation. R1 will return to the community on August 12, 2025.

Based on LPA record review and interviews, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the