Facility did not provide resident a safe environment causing injury

During the Department’s investigation it was revealed that resident (R1’s) most recent assessment was conducted on 4/4/22, R1 was a high fall risk, R1 did not require the use of any mobility devices, wanders often, and required partial assistance with redirection and cues, and R1 is mostly non-verbal with Dementia. The incident in question happened on 6/29/22 when R1 tripped on fan used to dry carpets after cleaning done at 5am-Incident report was submitted to CCLD 6/30/22, facility had other incident reports regarding R1 dated 2/10/22 and 7/12/22, facility did not reassess R1 after 6/29/22 fall, however, the assessment conducted on 4/4/22 indicated high fall risk. Facility contacted emergency services immediately after R1 fell on 6/29/22 and staff were present to assist. Facility staff were interviewed, and stated R1 was constantly walking throughout the facility. Care staff all stated the blower was positioned close to the wall and next to a chair, out of the walkway of residents. Staff stated R1 had fallen a few times, but R1 would more commonly lay themselves on the ground. No other residents have tripped over the blower. The facility agreed to clean the carpets after the residents are in bed.

Staff did not change resident timely

LPA interviewed staff (S1 and S2) who both indicated all residents are changed every 1 hour or 2, more if they need it because some residents go more than others. The staff (S1 and S2) indicated that there are residents that staff look out for because they go more frequently. Also, both staff indicated that if they notice a resident wet or solid, they change them right away it might take them 1 or 2 minutes, but they get them help quickly. LPA also interviewed residents (R2 and R3) and they were asked if they received help with their incontinence needs when they need it. Interviews with both residents indicated that their care needs are being met.

As a result of this investigation, LPA finds the allegations to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was provided to Administrator.