complaint·June 4, 2025

LPA conducted interviews with multiple representatives of resident (R1's) hospice agency, which indicated that they had no concerns regarding neglect on behalf of the facility. Interviews with hospice representatives indicated no concerns regarding the facility following R1's hospice care plan. LPA reviewed R1's Agency Discharge Summary with hospice representative, who indicated that the care plan was met by the facility. Interviews with Resident Care Director (RCD), Becca Deges, and Executive Director (ED), Alicia Rist, indicated that R1 was checked every two (2) hours. ED, RCD, and hospice representative stated that R1 had sometimes refused to use pendant. ED, RCD, and hospice representative indicated that R1 had their pendant with them on May 14, 2025 when they were found on the floor. ED, RCD, and hospice representative indicated that R1 had not used their pendant regarding fall. ED, RCD, and hospice representative indicated that staff had checked on R1 an hour prior to R1's fall on May 14, 2025. Based on interviews conducted and records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.