complaint·March 19, 2025

Staff's negligence and lack of supervision resulted in resident's fall. Department conducted record review, staff, and resident interviews to investigate this allegation. Facility records show that R2 was independent and was able to ambulate independently with an ambulation device (walker). Staff were instructed to remind R2 to use their walker when ambulating. R2’s needs and service plan did not indicate R2 was a fall risk or that R2 needed additional supervision based on history of falls. Based upon the information obtained during investigation, the above allegation is 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. Exit interview conducted. Report left with facility. Staff administered an overdose of prescribed medications that resulted resident's death. Records were reviewed regarding the death of R1. The Department was unable to obtain information that R1 was overmedicated by facility staff. Based on R1’s death certificate, cause of death was listed as Alzheimer's Disease, therefore, the above allegation is UNFOUNDED . A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility representative.