complaint·August 26, 2025

Record review shows R1s Needs and Service Plan was updated on 06/09/2025 with the goal for R1 to avoid injury from falls by assisting R1 with appropriate shoes when ambulating, verbally remind R1 to ask for assistance with transfers, escort resident to meals and activities, report any changes in condition to physician, staff check in routinely 4 times per shift, remind R1 to use walker as needed (keep within reach), and upon status checks staff are to ask R1 if they need to use the restroom and standby assist if R1 needs to use to toilet. R1s Needs and Service plan was updated after R1 had a fall on 06/18/2025; for nursing staff to ensure R1 has on proper footwear. R1 needs and service plan were updated after R1 had a fall on 07/12/2025 and 07/25/2025 and R1 was placed on hospice on 07/26/2025. Document review of facilities narrative charting notes for R1 reveal the falls happened in their bedroom and/or bathroom. Also review of narrative charting notes show staff documenting R1s falls, change of conditions, check-ins, and reminding R1 to use their cane/walker. 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.