complaint·January 5, 2026

***report continues from LIC9099*** Review of R1’s medical records documents that R1 sustained approximately 8 falls once a month, resulting in multiple injuries and at least 8 hospital visits. Also documented in R1’s medical records were that R1 was a fall risk, however after reviewing R1 care plan shows fall injuries were counted for and the facility does have a fall intervention in place including but not limited to frequent check in every two hours, clutter free, assistive devices are available in good repair, the bed in low position, half bed rails and with soft matting around the bed. According to the SOC 341 obtained by the department, RP stated that the hospital staff found R1 on the hospital floor. R1 was sent out on 11/28/2025 by the facility via ambulance with an unwellness fall, and it was determined that any fall R1 experiences needs to be sent to the hospital due to R1's care plan. Before sending out, R1 was assessed, and the record shows that R1 did not have any injuries, but due to R1's conditions. The facility followed procedure and called 911 to transport R1 to the hospital, and informed the family member that R1 was sent out. LPAs interviewed S1, S2, S3, and S4; all confirmed that they did carry out the care prevention plan for R1. This agency has investigated the complaint alleging residents sustain unexplained injury while in care. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted, a copy of this report provided.