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32 | Allegation: Due to lack of supervision, resident fell and sustained injuries
It is alleged resident was sent to the hospital due to a fall at the facility. It is alleged that the resident had multiple falls that led to bruising in multiple areas and will require a procedure.
Based on record review, resident #1’s (R1) physician report dated March 9, 2026, diagnosed R1 with Vertigo, Hypertension, nonambulatory, and recurrent falls. R1’s Preplacement Appraisal Form dated February 15, 2026, stated R1 uses a walker and can transfer themselves on and off by themselves. It also states the R1 needs help moving around the facility because they get tired quickly. An Incident report dated March 19, 2026, stated R1 was found on the floor on March 18, 2026, at 9:50 PM. R1 hit their head and was transported to the hospital. Primary Care Physician and Power of Attorney were notified.
The Facility charting notes for R1 stated on March 18, 2026, around 9:50 PM, R1 was found on the floor due to tripping and losing their balance. Staff observed R1 had an altered mental status and laceration on their forehead. R1 was transported to the hospital. Facility Charting Notes stated R1 returned to the facility on March 25, 2026, with a one-on-one caregiver present with them for 24 hours for three days.
Based on interviews, one resident, three out of three staff, and two witnesses denied the allegation. R1 stated that on March 18, 2026, at night, they were walking without their walker from their closet to their bed, which led to them falling that night. The fall occurred and R1 crawled to their bed for their pendant and pressed the button. R1 recalls the fall led to their hip pain and laceration on their forehead. R1 had an unwitnessed fall on December 17, 2025, which resulted with head pain. In both instances, R1 stated that they should have been using their walker. They know they should have used their walker to move around before they fell but chose not to use it in their unit. R1 stated the facility did nothing wrong and R1 needed to be more responsible. LPA observed R1’s unit, they had several signs posted up to remind R1 to always use their walker. R1 stated those were made by their son because of the fall on March 18, 2026.
Witness #1 (W1) and Witness #2 (W2) stated they do not suspect that the fall was due to negligence, lack of care, or lack of supervision. W1 stated that the facility does a good job in meeting R1’s activities of daily living. They stated the facility responded in a timely manner and provided the care and supervision based on
Continued on LIC9099C |