complaint·April 30, 2025

uses a walker for mobility and a wheelchair for longer distances. Transfers are generally minimal and staff may assist as needed. R1 requires staff supervision and occasional assistance during mobility, and there is no known or reported history of falls. Staff are instructed to observe and report any changes in gait or balance. A care plan dated September 20, 2024, notes that R1 requires mobility escort to and from meals and common areas, minimal assistance for transfers, and supervision to ensure safety. Safety checks are conducted four times per night during the NOC shift. Again, no history of falls was reported at that time. A resident assessment dated February 7, 2024, indicates that R1 uses a pendant call system, requires wheelchair escorts, and uses a walker. It also notes that R1 had a fall approximately 1.5 years ago while attempting to dispose of recycling. Staff interviews (3 of 3) revealed that staff became aware of the recent fall after observing bruising on R1. R1 reportedly stated they had fallen but could not recall specific details. Resident interview confirmed that R1 fell while attempting to get up from a recliner and lost balance. R1 also stated they did not report the fall to staff at the time. Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. This report was reviewed with Executive Director and a copy was furnished to the facility.