Complaint·March 4, 2025

However, R1 slid out of bed so there was no fall detected and no alert. This was the first time R1 slid out of bed, however it has happened twice more following this incident. R1’s private caregiver provided care to R1, and R1’s family and physician were notified. Per the care plan R1 is to be checked on during the night three times by staff. Care Services Manager (CSM) reminded all staff during shift change of R1’s specific and different routine, to ensure R1’s needs were met in the future. CSM stated service plans that are printed in the break room would be on updated to include preferred times of care, rather than just the care needed. CSM stated a care meeting was held 3/4/2025 with facility staff and R1’s health advocate. CSM discussed fall mitigation options such as a hospital bed, floor mat, hip pads, and using a Purewick system. Interviews indicated this was the only time R1 was found like this. Other residents interviewed indicated their needs were met. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview, technical violated issued, copy of report given, appeal rights given.