Inspection Reports for
Dermott City Nursing Home
702 West Gaines St, Dermott, AR 71638, AR, 71638
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
246% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 23, 2025
Visit Reason
The inspection was conducted following a complaint and incident involving Resident #1 who fell during a transfer, resulting in an acute right femur fracture requiring surgical intervention. The investigation focused on the facility's compliance with care plan implementation, resident transfer procedures, and administrative oversight.
Complaint Details
The complaint investigation was substantiated. Immediate Jeopardy began on 2025-12-02 when CNA #1 improperly transferred Resident #1 without required mechanical lift or two-person assistance, causing a fall and acute femur fracture. The facility failed to follow the resident's care plan and proper post-fall procedures. Immediate Jeopardy was removed on 2025-12-23 after corrective actions were verified.
Findings
The facility failed to consistently implement a comprehensive care plan for Resident #1, specifically regarding safe transfer procedures requiring a mechanical stand-up lift with two-person assistance. This failure led to Resident #1's fall and subsequent acute femur fracture. Additionally, the facility lacked a licensed Administrator since July 2025. Immediate Jeopardy was identified due to unsafe transfer practices and was removed after the facility implemented a corrective plan including staff education and monitoring.
Deficiencies (3)
Failed to ensure a comprehensive care plan was consistently implemented for Resident #1, resulting in improper transfer and fall.
Failed to ensure Certified Nursing Assistants demonstrated competency and followed care plan, leading to Resident #1's fall and acute femur fracture.
Failed to ensure the facility was administered by a Licensed Administrator in accordance with regulations.
Report Facts
Incident date: Dec 2, 2025
Pain level: 10
Fall risk evaluation score: 9
Fall risk evaluation score: 10
Residents requiring mechanical lift assistance: 27
Date Immediate Jeopardy removed: Dec 23, 2025
Date last Administrator resigned: Jul 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Involved in improper transfer of Resident #1 leading to fall |
| CNA #2 | Certified Nursing Assistant | Assisted in moving Resident #1 after fall without nurse assessment |
| LPN #5 | Licensed Practical Nurse | Reported fall incident to Director of Nursing |
| DON | Director of Nursing | Oversaw investigation and corrective actions |
| NP #3 | Nurse Practitioner | Ordered x-ray after Resident #1's fall |
| NP #4 | Nurse Practitioner | Provided expectations for resident transfers and assessments |
| CO | Compliance Officer | Interim administrator, involved in corrective plan implementation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 23, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall incident involving improper transfer techniques and failure to follow the resident's care plan, which resulted in serious injury.
Complaint Details
The complaint investigation was substantiated. Immediate Jeopardy (IJ) began on 12/02/2025 when CNA #1 improperly transferred Resident #1 without using the required mechanical stand-up lift or two-person assistance, resulting in a fall and acute right femur fracture requiring surgery. The IJ was removed on 12/23/2025 after the facility implemented a Plan of Removal including staff education and monitoring.
Findings
The facility failed to ensure proper implementation of a comprehensive care plan and adequate staff competency in resident transfers, leading to a resident sustaining an acute right femoral fracture after an improper transfer without the required mechanical stand-up lift and two-person assistance. The facility also lacked a licensed Administrator during the survey period.
Deficiencies (3)
Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and measurable actions.
Failed to ensure Certified Nursing Assistants demonstrated competency in resident care by moving a resident prior to nurse assessment following a fall and not following the resident's care plan requiring mechanical stand-up lift with two-person assist.
Failed to ensure a Licensed Administrator was hired to oversee day-to-day functions of the facility in accordance with federal, state, and local regulations.
Report Facts
Incident date: Dec 2, 2025
Pain level: 10
Fall risk evaluation score: 9
Fall risk evaluation score: 10
Residents requiring mechanical lift assistance: 27
Date of last Administrator resignation: Jul 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Involved in improper transfer of Resident #1 leading to fall and injury |
| CNA #2 | Certified Nursing Assistant | Assisted CNA #1 in moving Resident #1 after fall without nurse assessment |
| LPN #5 | Licensed Practical Nurse | Reported the fall incident to the Director of Nursing and confirmed care plan requirements |
| DON | Director of Nursing | Oversaw investigation and confirmed care plan and transfer protocol violations |
| NP #3 | Nurse Practitioner | Ordered x-ray and assessed Resident #1 after fall |
| NP #4 | Nurse Practitioner | Informed of fall and radiology results; stated expectations for transfers and assessments |
| CO | Compliance Officer | Provided policy review, expectations for care plan adherence, and confirmed lack of licensed Administrator |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to nurse staffing information posting, meal preparation and nutritional adequacy, food safety and sanitation, and resident care including bedding and positioning.
Findings
The facility failed to post required daily nurse staffing data including total hours worked and resident census, failed to prepare and serve meals according to the planned menu affecting residents on mechanical soft diets, failed to maintain proper food safety and sanitation practices, and failed to provide appropriate bedding for a resident dependent on staff for positioning.
Deficiencies (4)
Failed to post total number and actual worked hours for RNs, LPNs, CNAs and resident census on daily staffing logs.
Failed to ensure meals were prepared and served according to the planned written menu to meet nutritional needs for residents on mechanical soft diets.
Failed to ensure dietary staff washed hands and changed gloves before handling food; food items were uncovered; expired food was not removed; ice machine was not clean; hot foods not maintained at proper temperature.
Failed to provide appropriate bedding for a resident dependent on staff for positioning, resulting in discomfort and potential for contracture.
Report Facts
Residents affected: 21
Meals observed: 2
Food temperatures: 123.9
Food temperatures: 129
Food temperatures: 99.5
Food temperatures: 105
Food temperatures: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Interviewed about filling out staffing logs and census reporting |
| Director of Nursing | Director of Nursing | Interviewed about staffing logs and resident care |
| Business Office Manager | Business Office Manager | Interviewed about staffing logs and census data handling |
| Dietary Manager | Dietary Manager | Interviewed regarding meal preparation and food safety |
| DC #3 | Dietary Cook | Observed and interviewed regarding meal serving and food handling |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding resident bedding and comfort |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding resident comfort and bedding |
| Administrator | Administrator | Interviewed regarding resident care and bedding |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to nurse staffing information posting, meal preparation and nutritional needs, food safety and hygiene, and resident care including bedding adequacy.
Findings
The facility failed to post required daily nurse staffing data including total hours worked and resident census, failed to prepare and serve meals according to the planned menu affecting residents on mechanical soft diets, did not maintain proper food safety and hygiene practices including handwashing and food storage, and failed to provide appropriate bedding for a resident dependent on staff for positioning.
Deficiencies (4)
Failed to post total number and actual worked hours for nursing staff and resident census on daily staffing logs.
Failed to ensure meals were prepared and served according to the planned written menu for residents on pureed diets, including incorrect portion sizes and omission of pureed baked beans.
Failed to ensure dietary staff washed hands and changed gloves before handling food; food items were uncovered and expired items not removed; ice machine not maintained clean; hot food items not maintained at required temperatures.
Failed to provide appropriate bedding for a resident who required total assistance for repositioning, resulting in the resident lying without a pillow and potential discomfort or risk of contracture.
Report Facts
Residents affected: 21
Date of survey completion: Feb 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Interviewed about staffing log completion and census placement |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding staffing logs and resident care |
| Business Office Manager (BOM) | Business Office Manager | Interviewed regarding staffing logs and census data handling |
| Dietary Manager | Dietary Manager | Interviewed regarding meal preparation and food safety |
| DC #3 | Dietary Cook | Observed and interviewed regarding meal serving and food handling |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding resident bedding and comfort |
| Certified Nursing Assistant (CNA) #5 | Certified Nursing Assistant | Interviewed regarding resident comfort and bedding |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to safely transfer a resident, resulting in a major injury, and concerns about the facility operating without a licensed Administrator.
Complaint Details
The complaint investigation was substantiated by findings that the facility failed to safely transfer Resident #1, causing a major injury, and was operating without a licensed Administrator, which could affect all residents.
Findings
The facility failed to transfer Resident #1 safely according to the care plan, causing a major injury with a fracture to the leg. Additionally, the facility was found to be operating without a licensed Administrator, potentially affecting all 45 residents.
Deficiencies (2)
Failure to transfer Resident #1 safely according to the care plan, resulting in a major injury (fracture to fibula and tibia).
Failure to operate under the direction of a licensed Administrator, potentially affecting all 45 residents.
Report Facts
Residents affected: 5
Residents affected: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in transfer safety deficiency; attempted transfer alone and was not trained on care plan kiosk |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding training on care plan kiosk |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding training on care plan kiosk |
| Director of Nursing | Director of Nursing | Interviewed about staff training and facility operations |
| Acting Administrator | Compliance Coordinator / Acting Administrator | Confirmed no nursing home administrator license and lack of official assignment documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to safely transfer a resident, resulting in a major injury, and concerns about the facility operating without a licensed Administrator.
Complaint Details
The complaint investigation was substantiated by findings that RN #3 attempted to transfer Resident #1 alone despite the care plan requiring two staff and a mechanical lift, resulting in a fall and fracture. The facility also lacked a licensed Administrator since 7/15/2024, with an Acting Administrator unlicensed and no formal assignment documentation.
Findings
The facility failed to transfer Resident #1 safely according to the care plan, resulting in a fracture to the resident's leg. Additionally, the facility was found to be operating without a licensed Administrator, which could potentially affect all residents.
Deficiencies (2)
Failure to transfer Resident #1 safely according to the care plan, resulting in a major injury (fracture to fibula and tibia).
Facility failed to operate under the direction of a licensed Administrator.
Report Facts
Residents affected: 5
Residents affected: 45
Years RN #3 worked at facility: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Attempted unsafe transfer of Resident #1 resulting in injury |
| CNA #1 | Certified Nursing Assistant | Confirmed training on accessing care plans via kiosk |
| CNA #2 | Certified Nursing Assistant | Confirmed training on accessing care plans via kiosk |
| Director of Nursing | Director of Nursing | Provided information on staff training and facility policies |
| Acting Administrator | Compliance Coordinator / Acting Administrator | Confirmed no nursing home administrator license and lack of formal assignment documentation |
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Jan 5, 2024
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements including resident rights, care planning, notification procedures, rehabilitative services, food service, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including inaccurate documentation of residents' code status, failure to notify Ombudsman of hospital transfers, lack of PASARR screening for mental illness, incomplete care plans, failure to follow physician orders for rehabilitative services, unsafe storage of chemicals, failure to provide therapeutic diets and proper meal preparation, inadequate infection control practices, and ineffective quality assurance processes.
Deficiencies (14)
Failed to ensure accurate documentation of resident's CPR status in medical records.
Failed to notify Ombudsman of resident hospital transfer.
Failed to notify State Agency for PASARR for new mental illness diagnosis.
Failed to develop and implement care plan addressing cigarette smoking.
Failed to ensure rehabilitative services were carried out according to physician's orders for resident with contracture.
Failed to ensure janitor closet containing chemicals remained locked to prevent accidents.
Failed to follow therapeutic diet orders and assist resident with feeding leading to continued weight loss.
Failed to ensure meals were prepared and served according to planned menu and nutritional needs.
Failed to ensure meals were served at acceptable temperatures to encourage nutritional intake.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency.
Failed to ensure food storage, preparation, and handling met professional standards to prevent contamination and foodborne illness.
Failed to ensure proper hand hygiene and equipment cleaning in dietary services.
Failed to develop and implement effective Quality Assurance and Performance Improvement plans to prevent repeated deficiencies related to PASARR screening.
Failed to properly disinfect multi-resident use glucometer between uses to prevent infection spread.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 1
Residents affected: 25
Residents affected: 1
Residents affected: 4
Residents affected: 20
Residents affected: 35
Residents affected: 3
Total census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in glucometer disinfection finding and medication administration observation |
| Director of Nursing | Director of Nursing | Named in multiple findings including code status, PASARR, rehabilitative services, and infection control |
| Administrator | Administrator | Named in findings related to code status, Ombudsman notification, PASARR, quality assurance |
| MDS Coordinator | MDS Coordinator | Named in PASARR and care plan findings |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in care plan and feeding assistance findings |
| Dietary Supervisor | Dietary Supervisor | Named in food service and sanitation findings |
| Dietary Employee #1 | Dietary Employee | Named in food handling and sanitation findings |
| Dietary Employee #2 | Dietary Employee | Named in food handling and sanitation findings |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Named in pureed food consistency observation |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Named in food temperature observation |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Named in food temperature observation |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Jan 5, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding multiple deficiencies including inaccurate documentation of residents' CPR status, failure to notify Ombudsman of hospital transfers, failure to complete PASARR screenings for mental illness diagnoses, incomplete care plans, failure to follow physician orders for rehabilitative services, unsafe storage of chemicals, failure to maintain nutritional status, improper meal preparation and serving, food safety violations, inadequate infection control practices, and failure to implement effective quality assurance and performance improvement plans.
Complaint Details
The visit was complaint-related, investigating multiple allegations including inaccurate CPR documentation, failure to notify Ombudsman of hospital transfer, failure to complete PASARR screening, inadequate care planning, failure to follow physician orders, unsafe chemical storage, nutritional deficiencies, improper meal preparation, food safety violations, infection control lapses, and ineffective quality assurance.
Findings
The facility was found deficient in multiple areas including inaccurate CPR status documentation for Resident #39, failure to notify Ombudsman of Resident #42's hospital transfer, lack of PASARR screening for Resident #19, incomplete care plan for smoking for Resident #33, failure to provide rehabilitative services as ordered for Resident #19, unlocked janitor closet with chemicals accessible, failure to provide nutritional interventions and proper feeding for Resident #36, improper meal preparation and serving including incorrect portion sizes and food temperatures, poor food safety practices including expired and uncovered food items, inadequate hand hygiene and cross-contamination risks in dietary staff, and improper disinfection of glucometers leading to infection risk. The facility's Quality Assurance program failed to prevent repeated deficiencies related to PASARR screenings.
Deficiencies (12)
Inaccurate documentation of Resident #39's CPR status in the electronic medical record, conflicting with resident's advance directive.
Failure to notify Ombudsman of Resident #42's transfer to hospital.
Failure to complete PASARR screening for Resident #19 with new mental illness diagnosis.
Failure to develop and implement a care plan addressing cigarette smoking for Resident #33.
Failure to provide rehabilitative services as ordered for Resident #19 with contracture, including use of hand roll.
Janitor closet containing chemicals left unlocked with key in doorknob, accessible to residents.
Failure to provide nutritional interventions ordered by physician for Resident #36, resulting in continued weight loss.
Meals not prepared and served according to planned menu; incorrect portion sizes and inconsistent food temperatures observed.
Pureed food items served were not smooth and lump-free, risking choking for residents on pureed diets.
Food safety violations including uncovered and expired food items, poor storage practices, and inadequate cleaning and hand hygiene by dietary staff.
Improper disinfection of multi-resident use glucometer, risking spread of infection among residents.
Quality Assurance and Performance Improvement program failed to implement effective corrective actions to prevent repeated deficiencies related to PASARR screenings.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 1
Residents affected: 25
Residents affected: 1
Residents affected: 4
Residents affected: 20
Residents affected: 35
Residents affected: 3
Total census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Performed fingerstick glucose testing and improperly disinfected glucometer |
| Director of Nursing | DON | Interviewed regarding CPR status, rehabilitative services, weight loss interventions, and glucometer disinfection |
| Administrator | Interviewed regarding responsibilities for CPR status documentation, Ombudsman notification, PASARR screening, and Quality Assurance program | |
| Social Services Director | SSD | Interviewed regarding CPR status documentation and responsibilities |
| Certified Nursing Assistant #1 | CNA | Interviewed regarding care plan for smoking and feeding assistance |
| Dietary Supervisor | Interviewed regarding meal preparation, food safety, and dietary practices | |
| Dietary Employee #1 | Observed preparing and serving meals with improper hand hygiene and food handling | |
| Dietary Employee #2 | Observed preparing pureed food and improper hand hygiene | |
| Dietary Employee #3 | Weighed food portions served | |
| Certified Nursing Assistant #3 | CNA | Interviewed regarding consistency of pureed food |
| Certified Nursing Assistant #4 | CNA | Delivered unheated food trays |
| Certified Nursing Assistant #5 | CNA | Delivered unheated food trays |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 5
Date: Oct 13, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Dermott City Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity regarding catheter privacy, failure to complete required PASRR screening for a resident with a new mental illness diagnosis, failure to update the comprehensive care plan for that resident, failure to prevent a resident fall due to inadequate supervision during transportation, and failure to update the facility-wide assessment annually.
Deficiencies (5)
Failure to ensure a resident's dignity by not keeping a urinary catheter bag in a privacy bag.
Failure to notify the state agency for a Pre-admission Screening and Resident Review (PASRR) for a resident with a new mental illness diagnosis.
Failure to review and revise the Person-Centered Comprehensive Care Plan to reflect a resident's new diagnosis of Unspecified Psychosis.
Failure to ensure a resident was not left unattended during transportation, resulting in a fall.
Failure to update the Facility-Wide Assessment annually to determine necessary resources for resident care.
Report Facts
Residents affected: 44
Assessment or Update date: Nov 13, 2018
Resident BIMS score: 14
Resident BIMS score: 10
Fall history: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Interviewed about catheter bag privacy | |
| Certified Nursing Assistant (CNA) #2 | Interviewed about catheter bag privacy | |
| Certified Nursing Assistant (CNA) #3 | Interviewed about catheter bag privacy | |
| Certified Nursing Assistant (CNA) #4 | Interviewed about catheter bag privacy | |
| Certified Nursing Assistant (CNA) #5 | Interviewed about catheter bag privacy | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about catheter bag privacy | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about catheter bag privacy | |
| Director of Nursing (DON) | Interviewed about catheter bag privacy, PASRR screening, care plan revisions, facility assessment | |
| Administrator | Interviewed about catheter bag privacy, resident supervision during transportation, facility assessment | |
| Transport Assistant (TA) | Interviewed regarding resident fall during transportation | |
| Minimum Data Set (MDS) Coordinator | Interviewed about PASRR screening and care plan revisions | |
| Assistant Director of Nursing (ADON) | Notified about resident fall incident |
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 5
Date: Oct 13, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the facility's adherence to resident rights, care planning, safety, and facility-wide assessments.
Findings
The facility was found deficient in maintaining resident dignity related to catheter privacy, failure to complete PASRR screening and update care plans for a resident with a new mental illness diagnosis, inadequate supervision leading to a resident fall during transportation, and failure to update the facility-wide assessment annually. All deficiencies were assessed as causing minimal harm or potential for actual harm.
Deficiencies (5)
Failure to ensure a resident's dignity by not keeping a urinary catheter bag in a privacy bag, exposing it to view of others.
Failure to notify the state agency for a PASRR screening for a resident with a new mental illness diagnosis.
Failure to review and revise the Person-Centered Comprehensive Care Plan to reflect a resident's new diagnosis of unspecified psychosis.
Failure to ensure a resident was not left unattended during transportation, resulting in a fall outside a doctor's office.
Failure to update the Facility-Wide Assessment annually to determine necessary resources for resident care.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 44
Date of PASRR diagnosis: Sep 8, 2021
Date of MDS assessment: Sep 23, 2022
Date of MDS assessment: Aug 11, 2022
Date of Fall Risk Evaluation: Oct 6, 2022
Date of Care Plan initiation: Mar 23, 2022
Date of Facility Assessment: Nov 13, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed regarding catheter bag privacy |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding catheter bag privacy |
| Certified Nursing Assistant #3 | CNA | Interviewed regarding catheter bag privacy |
| Certified Nursing Assistant #4 | CNA | Interviewed regarding catheter bag privacy |
| Certified Nursing Assistant #5 | CNA | Interviewed regarding catheter bag privacy |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding catheter bag privacy |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding catheter bag privacy |
| Director of Nursing | DON | Interviewed regarding catheter bag privacy, PASRR screening, care plan revisions, facility assessment, and fall incident follow-up |
| Administrator | Administrator | Interviewed regarding catheter bag privacy, facility assessment, and fall incident follow-up |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding PASRR screening and care plan revisions |
| Transport Assistant | TA | Interviewed regarding resident fall during transportation |
| Assistant Director of Nursing | ADON | Notified about resident fall incident |
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