Complaint·July 8, 2025

Allegation: Facility staff are not properly supervising residents who are a fall risk - The reporting party (RP) alleges that Resident#1 (R1) sustained a fall injury in late December 2024. However, the RP states at the time of R1's reported fall, staff stated that R1 was doing "fine", suggesting that staff neglected R1's care. LPA's review of R1's records revealed the following: R1 was assessed as "non-ambulatory", however, is able to transfer from the bed and ambulate throughout the facility using a walker, requiring staff assistance and supervision. LPA interviews with Staff revealed the following: Staff refute the allegation, stating that facility caregivers consistently follow R1's care plan, are aware of R1's fall risk, and provide R1 with mobility assistance a minimum of three, or more times per day. Staff#2 (S2) states witnessing R1 on the floor during the fall incident and called additional staffers to assist R1. R1 was assessed, transferred to a wheelchair with staff assistance, and sent to the hospital for medical treatment; R1's responsible family member was informed. Based on the information gathered during this subsequent and prior initial visit, the allegation is deemed unsubstantiated at this time . Allegation: Facility staff did not seek timely medical attention for resident - The reporting party (RP) alleges that R1 was not provided medical attention in a timely manner. LPA's review of R1's records revealed the following: R1 was assessed as a fall risk, requiring some assistance when ambulating. R1's file does not show a a history of multiple falls prior to the fall incident in December 2024. Documentation reviewed shows that on the occasion of R1's fall incident. the facility followed proper procedures, including providing first aid, contacting medical professionals, calling 911, and sending R1 to the hospital when necessary. The facility also notified R1’s family following the fall incident. Additionally, facility staff state their awareness of R1' care plan and confirm providing consistent well checks and assistance for R1 to reduce the risk of further falls. LPA interview with R1's responsible family member (F1) revealed the following: F1 refutes the allegation, stating that facility staff consistently inform them of R1's health status and injury reporting and that R1 is well cared for by staff. Based on the information gathered during this subsequent and prior initial visit, the allegation is deemed unsubstantiated at this time . Based on records review, interviews with staff, and responsible family member, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.