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13 | Licensing Program analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility to investigate the above allegations. LPA Smith was greeted by the executive director and disclosed the purpose of the visit.
Residents are sustaining falls due to licensee neglect.
It was alleged residents are sustaining falls due to licensee neglect, specifically related to manual transfers. To investigate LPA Smith interviewed two (2) staff at 10:45 am, requested copies of documents relevant to the investigation at 10:50am, interviewed residents eleven (11) residents and (6) additional staff from 11:15 am -3:50 pm. Six (6) of nine (9) staff consistently stated that they have not observed any falls associated with manual transfers and stated that manual transfers are performed according to established procedures. The primary cause of recent falls involves residents not using their pendant to request assistance or attempting to ambulate without waiting for staff support per staff interviews. Ten (10) of eleven (11) residents interviewed confirmed that they receive assistance when they request it, five (5) of eleven (11) revealed that their falls occurred when they chose not to wait for staff or did not call for help, five (5) of eleven (11) |