complaint·May 20, 2025

In regard to the allegation “Staff did not address a resident's change in medical condition “, it is alleged that R1 arrived at hospital and had suffered a fracture from a fall. During interviews with Administrator, and staff three (3) out of three (3) stated that R1 had not fallen to their knowledge. Caregiver in the early morning had noticed swelling and redness and immediately acted by giving doctors order pain medication and calling for ambulance for pick up. Administrator stated that when asked R1 stated he/she had not fallen. During interviews with residents five (5) out of six (6) stated that staff seek medical attention if needed. R1 stated that he/she fell and that they did not tell staff. During investigation it was revealed that RP did not suspect abuse or neglect with resident however they were told that any fall should be reported. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was proved.