complaint·October 21, 2025

Per R1 physician report, R1 has “poor safety awareness…high fall risk” “lack of impulse control”, and “lack of hazard awareness”. Per record review of incident reports, between the months of August-October, R1 sustained a fall on 9/29/25 and 10/14/25, of which 911 was contacted both times to ensure R1 obtained medical care. Per record review, it also revealed that a care plan meeting was held on 10/15/25 with R1’s responsible party to address R1’s falls and change of condition. LPA conducted a tour of R1’s room and observed that there were no hazards or obstructions in the room and also observed that R1 has accessibility to a pendant button to alert staff when needed. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation 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. An exit interview was conducted with ED Howell. A copy of this report was provided and explained.