complaint·November 6, 2023

R1 received a care and toileting check every two hours when appropriate care is provided. Documents reviewed confirm that R1 received regular care/toileting check less than two hours prior to the fall. R1 was discovered on the floor during a regular a check. After the fall, facility staff assessed and monitored R1 and sent R1 to the hospital for additional treatment. Based on interviews and the review of documents, it was determined that R1’s fall was not due to a lack of supervision and the finding is Unsubstantiated. An exit interview was conducted and a copy of this report, and appeal rights were given to Karen Pultorak.