Complaint Investigation Report

Regarding the allegation, interviews consistently reported that R1 requires assistance with most activities of daily living, including assistance with transfers, and that staff regularly prompt R1 to use their call light pendant for help before getting out of bed. Interviews consistently stated that R1 sometimes attempts to transfer independently despite frequent reminders to wait for assistance, and will be successful with ambulating and transferring independently most times. Staff reported that on the night of the fall, R1 did not activate her pendant and yelled for assistance where staff was on the floor and able to hear and assist R1 promptly. Interviews also reported that staff conduct routine wellness checks on R1 every fifteen(15) to thirty(30) minutes.

Records review of R1’s assessment and service plan dated 03/27/2026 revealed that R1 requires staff assistance with ADLs, assistance to the bathroom, frequent room checks, fall prevention measures, and encouragement to use the pendant for assistance. Records also documented recent confusion, hallucinations, and mobility decline associated with medical conditions. The incident report submitted to the Department reported that R1 had an unwitnessed fall in their bedroom and stated they tripped and lost balance. EMS transport was initiated per protocol, and R1 was admitted to the hospital with altered mental status.

Based on interviews and records review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. An exit interview was conducted with Executive Director James Arp and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.