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32 | It was alleged that, due to lack of care and supervision, R1 had multiple falls at the facility that resulted in a head injury. LPA inspected the facility, conducted health and safety checks on R1 and other residents, and did not observe any health and safety issues. LPA reviewed R1’s Progress Notes which state that: on February 1, 2025, R1 had an unwitnessed fall, sustained a laceration to their head, was treated at a hospital, and returned to the facility the same day; on February 4, 2025, R1 had an unwitnessed fall, sustained a bruise to their head, was treated at a hospital, and returned to the facility the same day; and on February 5, 2025, R1 had an unwitnessed fall, did not sustain any injuries, and was seen by a nurse at the facility. LPA interviewed AD and one facility staff who reported that R1 moved in on December 9, 2023, was not a fall risk when they moved in, and had the facility’s basic fall prevention plan which includes encouraging residents to engage in the common area so they can be more closely monitored by staff and regular checks when they are in their rooms. LPA reviewed R1’s Physician’s Report dated November 29, 2023, which indicates R1 has Dementia, does not have any impairments relating to movement, is ambulatory, and can independently transfer to and from bed. Per R1’s Progress Notes, R1 had multiple falls in 2024. When interviewed, AD and facility staff stated that none of R1’s multiple falls in 2024 resulted in fractures or hospitalization, the facility reassessed R1 and noticed that R1’s balance issues were worsening, the facility held multiple care plan meetings with R1’s responsible party and updated R1’s care plan multiple times to address R1’s changing needs, and the facility conducted staff trainings on safe resident transfers, ergonomics, and gait belts. LPA reviewed R1’s Personal Service Plan dated January 1, 2024, R1’s Personal Service Plan dated August 30, 2024, and R1’s Personal Service Plan dated September 18, 2024, which corroborate that services were added to R1’s care plan as R1’s balance declined to ensure the facility was meeting R1’s needs with regards to their increasing fall risk. LPA also reviewed Staff Training Records that corroborated that the facility conducted additional staff training relating to falls. Per R1’s Progress Notes and interview with AD, R1’s falls in February 2025 did not result in hospitalization or fractures and R1’s laceration and bruise healed quickly with no issues. LPA reviewed R1’s Medical Records dated February 4, 2025, which indicate that R1 did not sustain any serious head injury from their fall on February 4, 2025. AD stated that in response to R1’s falls in February 2025, the facility took additional measures to address R1’s fall risk, including adding a fall mat, a wheelchair, and medication changes as facility staff had suspected one of R1’s medications was contributing to R1’s balance issues. Per AD and R1’s Progress Notes, R1 has not had a fall since February 5, 2025. LPA reviewed the facility’s staff schedule and did not note any staffing issues that may have contributed to R1’s falls. LPA interviewed R1’s responsible party who had no concerns about the care R1 was receiving at the facility. |