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32 | The investigation revealed the following:
Allegation: Staff do not provide adequate supervision resulting in residents sustaining multiple falls.
At approximately 8:20 AM, LPA Allen conducted interviews with six (6) staff members 1-6 (S1-S6). 6 out of 6 staff stated they had not personally witnessed R1 fall but were aware of previous incidents that have been reported and documented. Staff stated R1 needs and service plans are always followed however because moderate assistance is required staff does allow R1 privacy while helping with incontinent needs. Staff also stated R1 is consistently encouraged to remain in common areas where they can be assisted with their mobility/transfer needs and observations.
At approximately 10:25 AM, LPA interviewed five (5) Residents. LPA attempted to interview R1; however, R1 was unable to remain on topic and did not confirm or deny any falls and unable to have a clear conversation. LPA also interviewed R2 and R3 who stated they have not had any falls and there is staff there to help them. LPA attempted to interview R4 and R5, but they were unable to have a clear conversation.
At 11:20 AM, LPA Allen interviewed an external witness (W1), who reported that R1 has fallen or slid from their wheelchair on three occasions. W1 mentioned that the facility’s administrative staff had been in direct communication regarding R1's falls and expressed confidence that the staff were doing their best to ensure R1's safety. LPA Allen also reviewed the 2024 and 2025 physician reports, which indicates that stand-by to moderate assistance is required. Additionally, LPA Allen observed that there is a care plan in place for transfer and mobility, which specifies assistance with resident participation.
A review of R1’s file showed no documented designation of R1 as a fall risk or a need for a one-to-one ratio, though some assistance with activities of daily living (ADLs) is required. Documentation of R1's incidents also obtained and reviewed which shows staff did report the incidents for each occurrence.
Additionally, during the visit, LPA Allen observed staff members actively providing care, engaging with residents, and redirecting individuals as needed. There was sufficient staffing at the time of the visit.
Based on interviews, file review and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
An exit interview was conducted where this report was discussed and provided to Jodi Kanowitz Administrator at the conclusion of the visit with appeal rights. |