Allegation: Staff is not ensuring the residents has an updated care plan to include a fall plan

On 12/23/2025 LPA conducted interviews with Resident 1-8 (R1-R8).

LPA attempted to interview R1; however, R1 was unavailable. R3 stated that they have experienced falls in the past and believe their care plan is current. Residents R2, R4, R5, R6, R7, and R8 stated they are unsure whether their care plans are up to date and stated that they have not experienced any falls, either previously or recently.

LPA also interviewed staff members S1–S8, and 8 out of 8 staff members stated that each resident does have an update care plan on file which includes a fall plan if it applies to the resident. Staff members were also asked about the protocol regarding falls, and 8 out of 8 staff members stated that when a resident falls, the person who made initial contact with the resident makes observations and make sure the resident if ok or not, and contact is made with the medical technician (Medtech) or nurse on duty, who conducts a body check of the resident. If it is determined that any form of trauma is present, 911 is called immediately. Once the resident returns, and if necessary, their care plan is updated, staff are notified of required adjustments, and observations are made for the following 48-72 hours. During the visit LPA conducted a record review of eight (8) residents files which included needs and service plans, with physicians’ reports, and 8 out of 8 files appeared to be current.

Based on LPA interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. which means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of the report was provided to Nathaniel Venzon at the conclusion of the visit with appeal rights.