Complaint Investigation Report

Staff stated that they began actively looking for R1 when R1 could not be located for their evening medication pass. Staff elevated R1’s absence per protocol through their chain of command, and R1 was located on the ground within the enclosed gated yard where residents were allowed to freely roam. Staff assessed R1 for injuries and notified R1’s Hospice agency as well as their Responsible Party. Staff additionally informed that the outside doors to the enclosed yard areas remained unlocked and open often throughout the day, per the facility’s “51 Standards” model for memory care residents. Staff stated unanimously that R1 did not have any physical injuries after the incident, with the exception of a possible minor cheek abrasion/redness. Staff stated they were unsure if the cheek abrasion was from the incident on 08/02/2025, or from a different injury due to R1’s pattern of frequent falls.

Review of facility records corroborated staff statements regarding the timeline of events. The facility’s internal incident report and written statements from staff were consistent with staff statements made during interviews. Progress notes for R1 showed that R1 was placed on alert charting during the timeframe of concern and showed no signs of discomfort or pain after the incident occurred, vitals in normal range, and R1 presented at baseline. The facility’s “51 Standards” document stated that “Outside doors to enclosed yard areas are open every day and must remain open from 7:00am to 9:00pm”, corroborating staff statements that R1 was allowed to freely walk around the gated yard where they were found. Records did not give evidence that R1 was not being supervised according to their care plan during the time of incident.

An outside medical professional familiar with R1 (OS1) was interviewed; OS1 informed that R1’s baseline was to walk around the facility for long periods during the day. OS1 additionally informed that due to cognition, R1’s walking pattern was absent of R1 looking down to see where they stepped, resulting in frequent falls. OS1 informed that a fall mitigation plan was in place with ongoing care plan updates between the facility, R1’s Responsible Person, and R1’s Hospice agency. OS1 informed that they frequented the facility due to being involved with multiple residents and did not have concerns regarding the facility’s supervision of R1 or other residents. A second outside source (OS2) from an advocacy agency was interviewed; OS2 informed that they had not conducted an investigation regarding the incident at the time of the call, however based on prior visits they had no concerns about supervision at the facility.