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13 | Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a complaint investigation into the above allegations, met with the administrator Nick Gaither to explain the purpose of the visit.
Resident had a fall with a neck/femur fracture from before admission 2/6/26, however the recent 602, does have elements checked that do not support a resident need related to transferring and they are also noted as "supervised". Discharge documents have indepenedant and amulatory checked on a report from 2/6/26. interviews with the staff doing observation of the resident don't comport with a high fall risk prior to the 2/26/26 fall. Resident was not a monitoring system for the time of the fall, now staff observations and 1:1 walking assistance from a staff 2-3 times a day, staff get trained once a year with inservice(July) about fall type risks/ambulating for care and supervision. Supplemental trainings as needed are provided. Resident reported in interview a weakness in the legs, but overall not concerned with unmet mobility needs as she has staff assistance. Resident did sustain an injury as a result of an unwitnessed fall, its not strongly supported that the fall risk was something known or should have been known to the facility prior to the fall.
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