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32 | [Cont. from LIC 9099]
Regarding the allegation that R1 sustained injuries due to staff neglect, an incident that occurred on 11/20/2024, where R1 attempted to pet a visiting dog at the facility, resulted in the dog injuring R1 and causing a laceration that required medical attention. Interviews consistently reported that staff at the time of the incident responded immediately to the incident, contacted emergency services, and ensured the resident received prompt medical care. Staff further stated that the dog involved in the incident belonged to a visitor and that the staff involved had no ability to predict or control the behavior of the visiting animal. Staff also reported that R1 remained ambulatory following the incident, was assisted with ADLs as needed, and received ongoing redirection, monitoring, and wellness checks consistent with R1’s care needs. Interviews regarding a more recent fall incident that occurred on 05/18/2026, reported that R1 attempted to get out of bed independently in order to use the bathroom, resulting in an unwitnessed fall. Staff reported that they routinely encourage R1 to use mobility supports such as a walker, remind R1 to move slowly, and provide escort assistance as needed, however R1 often will refuse to use assistive devices.
Records review of R1's incident report from 05/18/2026 revealed an unwitnessed fall that occurred as R1 attempted to get out of bed to use the bathroom. Emergency services were called, and R1 was transported for treatment and diagnosed with a hip fracture requiring surgery. Review of R1's service plan documented that R1 was able to independently transfer and ambulate within the facility with walker use, required staff observation due to fall risk, and to receive regular status checks and reminders to use assistive devices. Records also revealed that R1 had a history of refusing assistance and demonstrating impulsive behaviors related to advanced Alzheimer’s disease.
Regarding the allegation that the facility did not ensure maintenance of R1's personal care equipment, specifically related to R1's hospital bed provided by a hospice agency, staff reported that they observed no mechanical issues with R1's bed prior to its removal. Staff consistently stated that the bed functioned properly, had operational half-rails, and assisted R1 with getting in and out of bed. Interviews further indicated that R1’s recent fall occurred as R1 attempted to get up independently despite being a high fall risk, and not due to any equipment failure. Interviews additionally reported that R1's bed was taken due to being discharged from their hospice agency following the fall since R1 was admitted to the hospital.
[Cont. on LIC 9099-C pg.1]
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