Regarding the allegation: Staff neglect led to resident death. It is being alleged that staff did not properly address resident #1 (R1)’s fall risk, which led to their death. The investigation included interviews with facility staff, residents, R1’s daughter, R1’s nurse practitioner, and physician, as well as a review of medical, coroner, and facility records. R1 entered the facility on 08/12/2025 and had two unwitnessed falls before their death on 09/23/2025. The first fall on 08/22/2025 caused a sprained ankle; the second on 09/19/2025 caused an intracranial hemorrhage. Post Fall Assessments were completed after each incident, and R1’s Needs and Services Plan documented their need for assistance with ambulation and all activities of daily living (ADLs). R1’s resident assessment, completed before admission, also addressed these needs. After the first fall, a staff member placed a foam mat around R1’s bed as a precaution. Staff consistently reported they were aware of R1’s fall risk. On the evening of the second fall, another staff member monitored R1’s due to their restlessness and checked on them frequently; R1 was found on the floor approximately 15 minutes after being returned to bed. 911 was called immediately. Hospital and coroner records confirmed an intracerebral hemorrhage from a ground-level fall. R1’s physician, and R1’s nurse practitioner, and facility staff explained that falls cannot be entirely prevented in seniors with their conditions. Based on the precautions taken and the available evidence, the fall was determined to be accidental, and the allegations of neglect/lack of supervision were found to be unsubstantiated.

Exit interview was conducted, no citation(s) were issued for the above allegation(s) and a copy of this report was given to the Executive Director.