complaint·June 5, 2025

The investigation revealed the following: Allegation: Staff did not provide adequate supervision resulting in resident sustaining a fracture. It is alleged that R1 sustained and unwitnessed fall that caused a non-displaced mandibular fracture, due to lack of supervision. IB investigator C.Ferris investigated the above allegation. Investigator reviewed surveillance footage of the incident that clearly showed R1 accidentally fall from their wheelchair and staff responded immediately to assist. R1 does not require assistance while using wheelchair. Investigator C.Ferris interviewed 1 witness (W1) and they stated they saw when R1 accidentally fell on their own and staff responded immediately. Investigator C.Ferris interviewed R1 and it was stated they were going too fast in their wheelchair and fell out. Investigator C.Ferris conducted file review where it was revealed that R1 is able to leave facility unassisted and able to care for their own needs. Per IB investigator C.Ferris this investigation did not provide sufficient evidence to substantiate the above allegation. Based on statements and interviews conducted with staff, R1 and W1, a review of R1’s file and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.