Based on interview and record review, conducted during a site visit on 06/04/25, the facility's failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

A review of Resident 1's progress notes dated 08/01/23 - 08/28/23 and 04/04/25 - 04/29/25 indicated Resident 1 experienced unwitnessed injury falls on 08/02/23, 08/08/23, 04/19/25, 04/22/25, 04/24/25, and an injury fall on 04/04/25 in which documentation was unclear if the fall was witnessed or unwitnessed.

A review of Resident Incident Reports for Resident 1's falls from 08/01/23 - 08/28/23 and 04/04/25 - 04/29/25, the facility was able to provide completed incident reports for falls on 08/08/23, 04/22/25 and 04/24/25.

There was no indication that any of the falls were reported to the local Department or the local AAA.

In an interview on 06/04/25, Staff 1 (Executive Director) and Staff 2 (Chief Compliance Officer) stated neither of them had worked in the facility during the timeframe and could not provide any more insight.

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse.

Findings were reviewed and acknowledged by Staff 1 (Executive Director), Staff 2 (Chief Compliance Officer), Staff 3 (CEO), and Staff 4 (Chief Clinical Officer).