Based on staff interview statements, R1’s facility assessment, physician’s report, and care plan, LPA determined the following information. R1 did have a fall that occurred on 3/1/2021 which resulted in a hip fracture. R1’s care plan, physician’s report, and resident assessment does not indicate that R1 is a fall risk. R1 is able to ambulate with minimal assistance from a cane per R1’s assessments and reports. All staff statements obtained indicate that R1 had no issues ambulating and R1 uses a cane from time to time. Staff statements indicate that there’s on average three to four staff working during the first and second shift in the Memory Care Unit (MCU). When R1 fell, R1 was utilizing a cane to ambulate. R1 has not had any prior falls during R1’s residency at the facility. RP and POA cannot confirm how many staff members were actually working in the MCU as facility was providing alternative visitation due to COVID-19.

2) Licensee did not ensure to communicate with responsible party.

Based on interview statements, R1’s internal progress notes, and incident reports, LPA determined the following information. R1 fell on 3/1/2021 and was assessed prior to being sent out to the hospital. POA was notified and an incident report was generated. POA is the responsible party for R1. Facility confirmed that they were made aware of R1’s hip fracture and R1’s required surgery from POA on 3/1/2021. POA confirmed that POA informed facility regarding the R1’s hip fracture and the required surgery on 3/1/2021. POA stated that the hospital contacted POA as POA is the responsible party. Facility stated that they do not get any information from the hospital as the facility is not the responsible party and the facility relies on family members for updates due to hospital policies. Facility confirmed that no attempt was made to obtain an update on R1 prior to POA informing the facility about the hip fracture and the required surgery needed.

Continuation on LIC 9099C.

Based on interview statements and observations on 10/7/21, LPA determined the following information. R1 resides in the MCU and shares a room with another resident. R1 did have a separate dresser as confirmed by RP and POA. RP stated that R1’s clothes were labeled so that they would be easily identified should there be a need to relocate. Upon R1’s move out from the facility, RP was unable to locate some of R1’s clothes as it was mixed with R1’s roommates’ clothes in the closet. RP was unable to specify what clothes were missing. LPA reviewed R1’s Personal Property and Values form and observed that a general description of “several clothes” were recorded. Due to the description and RP unable to recall what clothes were missing, LPA was unable to make any determination as to what occurred. LPA Cheng observed R1's room on 10/7/21 and observed that the room had two separate closets available for each resident.

Based upon the information obtained during investigation. The above allegations are 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.