complaint·January 5, 2026

CONTINUED FROM FORM LIC9099 Regarding the allegation that Resident fell due to lack of care and supervision , the following has been concluded: Based on the resident records provided by facility staff and reviewed during the investigation, R1 was admitted to the facility on May 28, 2019. At the time of admission, R1 was assessed to be ambulatory, with a primary diagnosis of Atrial fibrillation, hypertension, chronic kidney disease III, macular degeneration. R1 was assessed to be able to manage their own medication at the time and no indication of Mild cognitive impairment or dementia were noted at the time. Regular updates to R1's plan of care are noted based on changes in condition. For example, as of February 2020, R1 was placed on medication management. Per the physician orders reviewed, R1 had a PRN order for Albuterol which was documented to be administered regularly due to recurring shortness of breath. On or around January 12, 2021, R1 sustained an unwitnessed fall resulting in lacerations to the head which resulted in a call to the paramedics and evaluation at the hospital. R1 tested positive for COVID-19 while at the hospital and was placed on isolation as required upon being readmitted to the facility. As a result of the fall and COVID-19 diagnosis, recurrent follow-up assessments were conducted in the weeks that followed. Per incident reports submitted as well as charting notes reviewed, no other fall incidents occurred during R1's admission at the facility. R1 eventually passed while under hospice care in January 2024. The documentation reviewed fails to sufficiently evidence that inadequate supervision was being provided to R1 which would have resulted in the fall reported in January 2021. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.