complaint·September 4, 2025

Allegation 1: Unsubstantiated On 01/18/2025 R1 was found on the floor in their bedroom, conscious and complaining of pain to their hip and should areas. R1’s immediate cause of death was cardiopulmonary arrest. R1 did suffer from a hip fracture and shoulder dislocation, but was not an underlying cause of death. R1 had a history of falls and not following the directions of their POA and caregivers. R1 was properly trained on how to use the pendant and to use the transfer pole correctly. Non-slip mats were also provided. Caregivers correctly documented the fall, but it is unclear if their assessment of the injuries caused additional damage. The Department was unable to review R1’s medical records due to an objection filed by F1. Allegation 2: Unsubstantiated Staff reported that R1 valued their independence and preferred to do their activities of daily living (ADL) independently. R1 was oriented to themself, place, and time and lived in Assisted Living. R1 received several checks throughout the day for continence assistance. R1 was able to transfer into and use their walker and wheelchair. There is a record from staff with their attempts to educate R1 on how to appropriately use their call pendant. Outside physical therapy staff reported on 1/14/2025, “R1 was able to ambulate/transfer to and from their wheelchair, without their front wheeled walker.” Residents and staff who were interviewed had no concerns with lack of supervision. F1 had no concern with the care provided by staff. F1 was in agreeance with R1’s care plan despite their history of falls. Allegation 3: Unsubstantiated During the course of the investigation the department attempted to contact R2 and their POA. During this time R2’s POA refused to communicate with investigators and did not want R2 to comment. R2 had sores present on the genital area that S1applied medication to. It was reported R2 felt S1 applied the medication too aggressively. After the report staff and residents reported no other allegations of inappropriate behaviors by S1. Allegation 4: Unsubstantiated LPA and IB investigated the allegation that “Insufficient staffing to meet the needs of residents in care.” Through interviews, 2 of 3 staff members stated that they feel they could use more help. Care staff explained the recent departure of many coworkers due to pay. 1 out of 3 staff said they have not felt the burden from the other care staff leaving. Through interviews with residents 3 out of 3 were not concerned with the level of care they are receiving. Due to the information obtained, LPA finds allegation to be UNSUBSTANTIATED . 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.