complaint·April 8, 2026

(Continued from LIC9099) Department staff interviews revealed R1 frequently refused to sleep in the bed and instead slept in a recliner, which contributed to repeated falls or near falls. Staff stated that R1 did not consistently use ambulatory devices. Staff confirmed multiple unwitnessed falls and stated they responded promptly, contacted 911 when needed, notified the POA, and assisted R1 back to bed or chair as appropriate. Staff stated R1 was monitored with regular rounds. Department was unable to interview R1 due to discharge from the facility and subsequent placement. Department outside source interview revealed (OS1) they observed R1 attempting to stand from the recliner in an unsafe manner. OS1 reported never witnessing a fall during visits but observed balance issues, weakness, and progressive decline. OS1 also reported that staff appeared attentive and caring and observed multiple staff on duty and throughout the building during their visits. Department records review revealed that facility care notes documented repeated unwitnessed falls dating back to September 2025. Records repeatedly documented that R1 refused to sleep in the bed and preferred to sleep in a recliner, which may have contributed to falls when attempting to get up without lowering the footrest. Records also documented refusal or inconsistent use of the cane and shoes, intermittent confusion, and several instances of R1 sliding, kneeling, or being found on the floor. Department observations revealed on multiple occasions over the months that staff were present and attentive. Staff demonstrated knowledge of resident care needs and fall-risk protocols. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.