Complaint·May 14, 2026

S1 is no longer employed at the facility and three separate attempts were made to reach S1 by phone, however, S1 could not be reached to confirm or deny the allegation. Interviews were conducted with one witness, eight facility residents, and four staff. During their interview, R1’s responsible party, Witness 1 (W1), attributed R1's fall to their medical diagnosis and stated they were unsure if R1 had sustained a laceration or skin tear as a result of the fall. W1 stated they believed there could have been a lapse of about "15 minutes" between R1’s fall and R1 being found on floor, however, stated they did not believe it was two hours. Per W1, they had no concerns regarding the care provided to R1 by the facility. During their interview, seven of eight residents denied staff not providing adequate supervision and stated that in the event they need assistance they are able to alert staff using their pendant, and staff respond within minutes. One of eight residents stated their pendant has been tested by staff and they were informed it tested operational; however, they believe it often malfunctions and therefore, they use their personal cell phone to call for assistance and staff "come right away." During their interview, four of four facility staff denied having any knowledge of R1’s fall or injury and denied having knowledge of R1 or any other resident sustaining a fall with a two hour lapse in supervision by staff. Based on record review of R1's Care Notes and due to allegation being uncorroborated during interviews conducted, the Department is unable to determine if Facility staff did not provide adequate supervision resulting in resident being injured. Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.