complaint·December 2, 2025

(Continued from LIC9099) Staff interviews revealed that R1 was considered independent, used a walker, and was not known to be a fall risk. Staff confirmed that safety checks were conducted in the morning and evening, as well as during the NOC shift. They further report R1 was social, independent, and regularly seen walking with her walker. They acknowledge that R1 reported and they observed cold-like symptoms the night before the incident, but no additional concerns were noted. Outside source interview confirmed that R1 was independent but had recently shown signs of weakness. The family had declined additional care services due to financial limitations. Records review showed that R1 was receiving additional safety checks as of October 2024. No prior falls were documented. LPA observations and interviews confirmed that the facility had systems in place for routine safety checks and that R1 resided in the assisted living area. 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 Chris Neale. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to ED Neale whose signature below verifies receipt of these right. [See LIC 811 Confidential Names List to identify Resident #1]