Complaint Investigation Report

R1 stated staff were aware of both falls. LPA observed R1 to be in good condition. Interview with the administrator at 12:45 p.m. on 04/29/26 revealed the facility was aware of R1’s falls and submitted incident reports for both. Interview with the Wellness Director at 1:20 p.m. on 04/29/26 revealed the facility followed standard fall protocol and reassessed R1’s needs on 04/20/26. Record review of R1’s medical assessment, care plan, and hospital discharge paperwork showed no changes in condition. R1’s medical assessment revealed a diagnosis of minor cognitive impairment which was addressed on R1’s care plan and reassessment form. Record review also confirmed the facility submitted incident reports for both of R1’s falls. Staff also documented the falls in their daily notes and monitored R1 for pain. Based on observations, interviews, and record review, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Resident fell sustaining injuries due to lack of supervision" it was alleged R1 fell during a walk outside of the facility which should have been supervised. Interview with R1 revealed they walk outside every day and have done so for twenty (20) years. R1 noted they do not require supervision while walking. Interviews with the administrator and Wellness Director confirmed R1 goes on daily walks and does not require supervision. R1 was assessed by the facility on 04/20/26 and was determined to not require assistance with walking. Record review of R1’s medical assessment deemed them capable of leaving the facility without assistance or supervision. Based on interviews and record review, R1 did not fall due to lack of supervision since R1 did not require supervision. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No immediate health or safety concerns were observed during today’s visit.

Exit interview conducted. Copy of report provided.