complaint·July 23, 2024

Since R1’s fall, R1 is not allowed to walk alone, and staff walks with R1 when the resident takes neighborhood walks. According to one of the staff members interviewed, the caregiver will observe R1 walking from the porch as the resident walks. R1’s physician’s report dated August 10, 2022, states R1 can leave unassisted, and R1’s updated physician’s report dated October 13, 2023 also states R1 can leave unassisted. However, S1 said after R1’s fall, the physician’s report needs to be updated and changed because R1 no longer leaves unassisted. Based on the information gathered during the investigation through interviews and document review, the Department 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, the allegation is deemed Unsubstantiated.