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32 | LPA obtained a copy of a separate LIC624, which indicated that on March 2, 2026, R1 had been found on the floor by Staff 2 (S2). R1 was unresponsive and pale, however, no signs of any injuries were observed. 911 was called and R1 was transported to the hospital. S2 was interviewed and stated that at the time of the incident they were doing physical rounds and check-in on residents, when they found R1 on their bedroom floor. Per S2, they were unsure how long R1 had been on the floor prior to being found and stated R1 was initially unresponsive. S2 stated they called 911 and by the time paramedics arrived R1 was speaking and stated they had slid down their bed. Per S2, R1 had not sustained any injuries, however, they had made the decision to call 911 for further evaluation as R1 was not at baseline.
During interview, R1’s responsible party, Witness 1 (W1), stated they were unable to recall the exact dates and times but estimated R1 sustained approximately “three or four” falls while residing at the facility. W1 denied the falls were a result of lack of care and supervision and stated, “it didn’t appear and it does not appear to be an issue with staff.” Per W1, R1 was relocated to a skilled nursing facility not only due to falls, but due to increasing physical and medical needs. LPA attempted to interview R1, however, a phone number where they could be reached was not available.
Based on information gathered, the Department did not find sufficient evidence to support the allegations, “Lack of care and supervision resulting in resident sustaining multiple falls”. 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 above allegation is Unsubstantiated.
An exit interview was conducted and copy of this report was provided at the end of the inspection. |