complaint·January 22, 2025

Of the four (4) calls for service, one (1) call was made relating to a fall the resident sustained. Two (2) of four (4) calls for service resulted in R1 being admitted to the hospital for additional medical treatment. An AMR (American Medical Response) Patient Care Report, dated 10/21/2024, revealed AMR responded to the facility for R1 who experienced a witnessed ground level mechanical fall. The report revealed the resident presented alert and oriented times two (X2) with no medical complaints. According to the report, facility staff explained how R1 fell forward while walking outside, losing their footing on a curb. The report revealed R1 denied hitting their head, did not lose consciousness, and did not want to go to the hospital. The report revealed facility staff expressed their desire to have R1 transported due to the mechanism of the fall and R1's recent behavior challenges with staff. R1 was later transported to a local hospital. An Unusual Incident/Injury Report (UIR) from the facility was available for review for the 10/21/2024 incident. The report revealed R1 was exit seeking, exited the memory care building into the secured courtyard, started swinging at staff, and fell onto their knees after tripping over a flower bed. The report revealed R1 complained of pain to their knees after their fall. Staff #1 (S1) was identified to be present during the incident in both the AMR Patient Care Report and the UIR. An interview was attempted with S1; however, no response was received prior to the closure of the investigation. R1 also could not be reached for an interview prior to the closure of the investigation. No additional information was obtained that could either refute or corroborate the validity of the allegation. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with Executive Director Abrego-Huerta and a copy was provided.