Facility Evaluation Report

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation (26-AS-20260310091638). The purpose of this case management-other visit was to review and address concerns identified during the investigation of the above referenced complaint that are unrelated to the allegation. LPA met with Administrator Meghian Geul

During the complaint investigation, R1’s facility file record was reviewed and identified multiple documented falls and injuries involving R1 from November 22, 2025- February 24, 2026.

The Department reviewed R1’s Progress Note with the following noted observations:

November 22, 2025: at 5:15pm, care giver called the medtech, noting that R1 had fallen. R1 had slipped on the floor and hit his/her buttocks. R1 denied hitting his/her head.

December 14, 2025: at 4:30pm, R1 pushed his/her pendant and the care giver found R1 sitting on his/her buttocks, in his/her apartment closest. R1 claims he/she did not hit his/her head and did not have pain.

December 16, 2025: Per R1, he/she stated he/she had a fall last night at 4:00am. R1 denies hitting his/her head and pain. R1 appeared confused and stated that his/her belongings are missing.

December 20, 2025: At 2:49am, R1 reported to care giver that he/she had a fall besides his/her chair. R1 was assisted back to his/her chair. No complaints of pain or discomfort. Staff noted skin tear about 2 inches wide on his/her right elbow. Cleaned wound and applied bandage.