Complaint·February 5, 2026

Allegation: Facility staff does not ensure resident is provided adequate supervision resulting in multiple falls while in care. The allegation alleges a resident experienced three (3) falls from their bed during the month of December 2025. During the facility inspection, LPA observed staff escorting residents to meals, activities, and the restrooms. LPA observed some residents have hip protectors on. LPA observed in rooms 101, 225, and 116, the beds are on the lowest setting and there are fall mats to the side of the beds. During record review, LPA received and reviewed the Staff Schedule that indicates there are two (2) caregivers and a nurse working the NOC shift. LPA received and reviewed Staff S3-S8 training logs that indicate they have received the following training on Relias within the last year, Silverado Fall Management for Residents with Dementia, Slip, Trip, and Fall Prevention, and Minimizing Slips, Trips, and Falls. LPA received and reviewed in-service logs that indicate staff received training regarding Hip Saver, Fall/Injury Management, Prevention, and Precautions. LPA received and reviewed Incident Forms dated 12/02/2025 and 12/21/2025, that indicated Resident R1 was observed on the floor. The reports state there were “no signs of injury” and R1 was “unable to verbalize what occurred.” One report stated R1 was assisted back to bed and “magnet bed alarm was placed.” Additionally, LPA received and reviewed R1’s Nursing Admission Evaluation Results and Service Plan, dated 11/10/2025, that indicates R1 has a history of falls, but not within three (3) months of the assessment. LPA observed R1 uses ambulatory aids such as a walker or cane, and “may require hands on assistance by staff” when ambulating and transferring, and “cues for safety.” In R1’s Charting Notes, LPA observed S2 and W1 met on 12/23/2025 to discuss implementation of a second alarm in addition to the tag alarm. During interviews with Staff S1-S8, were asked if they feel there is enough staff on each shift to provide adequate supervision to prevent or minimize falls, seven (7) out of eight (8) stated yes, they feel there is enough staff to provide adequate supervision to minimize falls. During interviews with Residents R2-R6, they were asked if they feel there is enough staff to provide adequate supervision to prevent or minimize falls, five (5) out of five (5) stated yes, they believe there is enough staff to provide adequate supervision. Additionally, Residents R2-R6 were asked if the facility take precautions to minimize falls, four (4) out of five (5) stated yes, the facility takes precautions to minimize or prevent falls. One (1) resident stated they do not have any concerns regarding falls. During interviews with Resident’s Responsible Parties W1-W6, they were asked if staff provide adequate supervision to prevent or minimize falls, five (5) out of six (6) stated yes, they believe there is enough staff to provide adequate supervision to prevent or minimize falls. Additionally, six (6) out of six (6) stated the facility takes precautions to minimize or prevent falls. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated . LPA did not observe or cite any deficiencies during today’s visit. An exit interview was conducted with Executive Director, Christina Hale, and a copy of this report was provided.