complaint·April 14, 2026

Per interviews with 2 out of 2 residents stated staff assisted them in a timely manner and their needs are met. Per review of Resident 1's (R1) physician report resident does not have motor impairment. Per service care plan R1 requires minimal fall assistance, per ED minimal assistance means escorting to and from dining and activities. Per review of incident reports R1 had 3 falls in between 02/13/2025 to 1/20/2026, R1 was taken to the hospital after each fall and R1's primary care physician was notified. T he last fall occurred on 01/20/2026 around 1:00 PM, the resident was found on the activity room floor in Memory Care. R1 stated they were attempting to sit in a chair, missed the chair, and fell backward. Per incident report resident was sent out to the hospital after being assessed and assisted by staff at the facility. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation Facility did not prevent resident falls due to lack of staffing is determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. No deficiencies cited. An exit interview was conducted and a copy of this report was provided.