Complaint·December 9, 2025

Continued from LIC9099... Staff 1 (S1) learned that R1 had a controlled fall on 6/24/2025 when Staff 2 (S2) and Staff 3 (S3) were waking R1 up. S1 assumed that staff had R1 slide from the bed to the floor. R1 did not have any indications of pain at this time. R1 would not be able to say if they were in pain. Staff 4 (S4) stated that S2 was responsible for waking R1 up and changing their incontinent briefs. S2 told S4 that they dropped R1 while changing their briefs. S3 was unaware of R1 falling but stated that it was possible for S2 to have changed R1 alone resulting in R1 falling. S2 denied knowing anything about R1 being dropped or sliding to the floor. All of the staff knew that R1 was to be changed or moved with two staff present for a two person transfer. Based on observations made, interviews conducted, and records reviewed, the Department received conflicting information regarding the above allegation. Based on interviews conducted, observations made, and records obtained, the allegation staff neglect resulted in resident sustaining a fracture is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Director of Operations, whose signature on form confirms receipt of document(s).