complaint·November 30, 2023

During the investigation process interviews and a records review was initiated. LPA Avila reviewed incident reports and physician report. Records reviewed indicated that resident falls are in large part due to physical and medical implications. LPA Avila reviewed facility records and each fall was documented and sent to the Department and Hospice Services. The facility has updated care plans for residents addressing fall behaviors. According to R1s physician’s report that was completed on 09/05/2023, R1 is ambulatory. R1 is not a fall risk. The physician report stated facility is to provide physical assistance to and from the dining room and or community activities as needed. Interviews that were conducted stated when residents would fall, staff immediately would assist residents. A minimum of two staff members would assist the resident who had fallen. 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, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of the report was provided to Nate Echols.