complaint·December 17, 2025

Additionally, staff stated that they followed R1’s plan to reduce falls, but R1 did not call for assistance. Additional information received from interviews indicated that staff did remain with R1 until first responders arrived. Information obtained from an interview with R1 described that they attempted to get out of bed without notifying staff that they need assistance. R1 corroborated that they refused medical care as they were not experiencing pain. R1 stated they have not experienced staff delaying assistance for unreasonable amounts of time. R1 indicated there are no concerns with how the facility staff attend to their daily needs or supervision. Information obtained from interviews with additional residents indicated they feel safe while at the facility and have no concerns about how staff attend to their daily needs. Information obtained from interviews with Additional Witness indicated R1 had an unwitnessed fall and that R1 refused to be transported for further medical evaluation. On several unannounced visits, LPA observed R1 attempting to get up out of their wheelchair, prior to calling staff for assistance. A review of the records, including the facility’s policy and procedure regarding reporting, corroborated the information obtained. An additional review of the records, including R1’s needs and service plan, confirmed R1 is a fall risk and R1 is to call for assistance prior to transferring from their wheelchair. Based on information obtained from interviews, record reviews, and observations, the evidence received pertaining to the allegation that staff are not properly supervising a resident who is a fall risk has been deemed unsubstantiated. An unsubstantiated allegation means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted. A copy of this report was discussed and given to the Administrator, Brooke Huerta.