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32 | W1 states R1 had four falls during these six months (May 2025 to November 2025). W1 states R1 was checked frequently by facility staff during the time the falls occurred. W1 stated R1 is ambulatory and uses a wheelchair and can self-transfer (to and from the wheelchair). W1 states he/she does not believe R1 fell due to staff neglect.
Review of R1’s physician’s report dated 2/8/2024, R1 is noted to have motor impairment/paralysis, walks with a cane.’ R1 is non-ambulatory due to physical condition.
Review of R1's progress notes from 5/1/2025 to 11/29/2025, R1 is being checked on by facility staff with noted incidents of R1 falling on 11/14/2025, 10/24/2025, 9/22/2025, and 5/6/2025. R1 was assessed by facility staff, and all responsible parties were notified of the falls.
Review of R1’s care plan dated 10/22/2025, for ‘Escort & Mobility’ R1 is noted as “independent going to and from the dining room or community activities, resident has falls in the last twelve months, resident has fallen without apparent harm/injury, resident uses a cane as a mobility aid, resident uses a walker as a mobility aid, resident uses a manual wheelchair as a mobility aid."
Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with ED and a copy of this report was provided.
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