complaint·September 15, 2025

The investigation revealed the following: Allegation: “Resident sustained unexplained injury while in care due to staff neglect.” It is alleged that R1 has dementia and frequently falls several times a day, including an unwitnessed fall on August 11, 2025, resulting in left hand injury. (4) out of (4) staff interviewed stated that caregivers conduct routine checks every 2 hours or more often if needed. However, R1 requires a higher level of care or 1:1 supervision because of their medical condition and R1 does not have a one-on-one caregiver. Staff interviewed stated that when R1 had a n unwitnessed fall on 08/11/2025, a med tech was called by a caregiver who immediately assessed R1, provided first aid and sent R1 to the hospital, where R1 stayed until August 15, 2025, and received stitches for the injury. Additionally, staff interviewed stated they also provided fall mats to R1 and increased their physical therapy sessions to help prevent R1 from falling and sustaining injuries. All (9) residents interviewed denied the allegation, while (7) of the (9) were unaware of the incident. (3) out of (9) interviewed residents experienced a fall and stated the staff conducted body checks, assessed and attended to them. Residents interviewed also stated that staff conduct routine checks daily. Therefore, there was insufficient evidence to corroborate with the allegati on. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the 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 conducted and a copy of this report was provided to Bryanna Luke, Administrator.