complaint·December 22, 2025

During today’s visit, the LPA and ACDs conducted a physical plant tour at 1:40PM and no immediate concerns were observed. The following was then determined: Allegation: “Due to staff negligence, resident fell resulting in an injury” It was reported that Resident #1 (R1), a known fall risk, sustained a fall on 06/18/2025 that resulted in a sprained ankle due to staff negligence. Interviews with five (5) residents revealed that falls do not often occur in the MCU and that staff are consistently nearby to provide assistance. Residents reported utilizing assistive devices such as walkers and wheelchairs to prevent falls and stated that staff respond immediately and appropriately if a fall does occur. Staff interviews revealed that fall prevention protocols included motion censored floor and bed mats, bed rails, fall detection cameras in each resident room, and monitoring for behavioral changes. Staff reported that falls in the MCU are infrequent and, when they do occur, they are often “staff assisted,” meaning staff guide residents safely to the floor. Unwitnessed falls reportedly occur on average zero (0) to one (1) time per month. Staff stated that fall procedures include notifying all staff via radio, ensuring the resident is safe, and placing a pillow under the resident’s head. The med-tech and LVN (nurse) then assess the resident’s condition, including range of motion and pain. The LVN also reviews fall detection footage to confirm the fall and determine whether the resident may have hit their head and then decides if hospital transport is necessary and notifies the resident’s family and hospice agency. Staff reported that R1 was initially capable of independently ambulating and required minimal staff assistance with activities of daily living (ADLs). Over time, R1’s condition declined and R1 required assistance with all ADLs. R1 was considered a fall risk when ambulating due to unsteady, shuffling, and twisting feet and required arm support for balance. Staff preferred utilizing R1’s wheelchair for transfers and escorts and reported that R1 received physical therapy (PT). Staff stated they expressed safety concerns to R1’s family; however, the family insisted that staff continue assisting R1 with walking. Report Continued on LIC 9099-C Staff observed family-hired private caregivers assisting R1 with walking and noted instances where R1 appeared to be dragged, prompting staff to intervene. The MCU director stated the facility does not provide two (2) person walking assistance, as this indicates unsafe ambulation. Staff also reported that following R1’s fall, the facility conducted additional in-service training on fall prevention. On 06/18/2025, R1 sustained a fall in their room while Staff #1 (S1) assisted with R1’s morning ADLs. S1 stated they intended to use R1’s wheelchair to escort R1 to the restroom; however, R1 showed signs of wanting to walk. S1 attempted to comply with the family’s request for assisted ambulation. S1 briefly let go of R1 to move the wheelchair out of the path, at which point R1 took several steps independently, lost balance, hit the wall, and fell. Fall detection footage showed S1 entering R1’s room at 7:45AM and providing assistance with ADLs including dressing and incontinence care. S1 positioned R1’s wheelchair at the foot of the bed and walked R1 toward it for support while finishing with dressing. At 7:51:47AM, S1 assisted R1 in letting go of the wheelchair and took five (5) steps toward the hallway before turning to reposition the wheelchair. R1 continued walking independently, taking an additional five (5) steps before losing balance at 7:51:53AM. At this time, S1 turned back toward R1 and immediately rushed to R1. R1 fell leaning towards their left, hit the wall, and hit the floor. S1 notified staff and placed a pillow under R1’s head. The MCU med-tech arrived and conducted an initial assessment, followed by the LVN who completed a secondary assessment. At 7:57AM, R1 was placed in their wheelchair and S1 continued assisting with ADLs. R1’s Resident Appraisal dated 11/03/2023 indicated R1 was ambulatory without assistance. The Resident Assessment and Service Plan dated 07/03/2025 documented R1 to need hands-on assistance with showering, dressing, grooming, incontinence care, feeding, and transfer assistance by one (1) staff with escorts to and from meals and activities. It was also noted that R1 required increased room safety checks due to fall risk and was wheelchair bound. Report Continued on LIC 9099-C Physician Report dated 07/10/2025 indicated R1 was receiving hospice services for a diagnosis of end stage dementia, was non-ambulatory and required assistance with repositioning and transferring. Post-fall X-Rays on 06/21/2025 and 07/02/2025 ruled out fractures on R1’s spine, hips, and knees. A doctor’s visit summary on 07/18/2025, noted the family reported R1 was “walking with some assistance” prior to the fall. The physician assessed R1 as having diffuse sarcopenia and a left ankle sprain as a result from their fall. PT records documented services beginning 03/29/2024 through discharge on 07/21/2025. R1 received therapy to improve fine motor coordination, muscle strength, functional activity tolerance, and standing balance with the goal of independently performing ADLs. R1’s baseline on 09/01/2024 indicated the ability to maintain balance against moderate resistance for approximately ten (10) minutes with standby assist (supervision) for safe ambulation. Additionally, R1 demonstrated fine motor coordination with stand by assistance. On 05/22/2025, PT documented that R1 required maximum arm assistance for gait activities and maximum assistance with transfer. Service Logs recorded ten (10) PT visits post-fall. A PT assessment on 06/25/2025 indicated R1 had potential for improvement but progress was slower than expected. PT documented that R1 required skilled rehabilitation due to impairments including balance deficits, decreased body awareness, cognitive decline, decreased dynamic balance, reduced functional tolerance, decreased attention, strength impairments, pain, and postural alignment issues. Based on interview and record review, R1 was appropriately assessed as a fall risk, and staff were aware of and responsive to R1’s changing condition. Although R1 sustained a fall resulting in an ankle sprain, there is not sufficient evidence to prove the alleged violation was a result of staff negligence, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.