complaint·October 31, 2025

Allegation: Staff left resident on the ground for an extended period of time. It is alleged that on October 22, 2025 at approximately 10:00 PM, emergency personnel responded to a fall incident, in which resident (R1) was found sitting on the ground in the middle of the room next to their bed. It is unknown how long the resident was on the floor. The complaint alleges caretaker negligence because staff wait for fire department personnel to arrive on scene to complete a basic assessment. Emergency personnel deemed R1 oriented to name, age, city and when asked about pain and injury the resident denied injury. A total of nine (9) residents were interviewed. Three (3) of the residents interviewed recently fell. The residents stated staff respond and leave the residents on the floor until paramedics arrive in case there is broken bones or head injuries. A total of seven (7) staff were interviewed. Staff interviews revealed that resident (R1) is cognitively impaired and resides in the Memory Care Unit of the facility. According to staff, facility protocol in the Memory Care Unit is to call 911 if there is any accident involving a possible head injury, such as and un-witnessed fall. Staff stated that the PM care provider on duty did their last safety check prior to ending their shift at 10 PM, and found the resident sitting on the floor with cris crossed legs. The med-tech on duty was notified, and called 911. While waiting for emergency personnel med-tech assessed the resident by asking them questions and conducting a visual body check. All staff stated that since the resident has Dementia and is a fall risk the followed facility procedures that indicate whenever a Memory Care Unit resident falls they are to immediately call 911 because the residents are cognitively impaired and may not be able to express a change in condition. Based on file review of the Plan of Operation, facility policy regarding medical emergencies- calling 911, and R1's file documents, which indicate the resident is under fall management, there is insufficient evidence to support the allegation. Allegation: Staff are refusing to lift resident back up off the floor. The complaint alleges facility staff called 911 emergency because they needed help in lifting resident (R1) after they fell. It is suspected the facility is using 911 for non-actual emergencies, and expected emergency personnel to lift and transport the resident to bed, even though R1 did not require medical treatment and was not going to be transported to a hospital for treatment. Resident interviews revealed that staff leave the residents on the floor when they sustain falls, and if they are not transported to a hospital staff lift the residents from the floor. All staff denied the allegation, and stated they did not ask emergency personnel to lift R1. They stated that they follow facility procedures that indicate they are to leave any resident that sustains an unwitnessed fall on the ground until emergency personnel assess the resident. Staff stated it is the care provider's responsibility to place a resident back on their bed or chair after they have fallen if they are not transported to the hospital. Staff stated they do not expect emergency personnel to assist with lifting residents if they are not transported. There is insufficient evidence to support the allegation. 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 discussed and provided to Kimberly Sanchez.