Complaint·July 14, 2025

Allegation: Resident sustained fractures while in care due to neglect.-Unsubstantiated Resident #1 (R1) was not documented as a fall risk and did not require two- hour checks. R1 stated their fall occurred in their room without any witnesses in October 2022. When staff did respond to the fall, R1 confirmed they refused to be transported to the medical center for further assessment. Allegation: Staff failed to seek resident medical attention in a timely manner.-Unsubstantiated In an interview with R1 they confirmed they refused to be transported to a medical center for further assessment of injury after their fall in October 2022. Facility did keep records of R1 reporting they had no pain in the following days. R1 did not inform staff that they were going to the doctors due to an injury after the fall. R1 was found to have a “minimally displaced fracture of undetermined age.” Records reviewed documented R1 as having a pathological fracture. Consulting physicians explained this type of fracture implies the fracture was a result of underlying illness of disease. Allegation: Insufficient staffing to meet residents' needs. - Unsubstantiated The department conducted interviews with staff and residents. Staff interviews indicated they feel like they have enough staff to meet the needs of the residents in care. Resident interviews indicated that some residents feels like their needs are being met. While others feel like their needs to be more checks throughout the day. LPA conducted a tour of the facility and observed multiple staff members on the floors assisting residents. Allegation: Staff failed to respond to resident's call assistance button in a timely manner. - Unsubstantiated A sample of resident call button response logs was reviewed for the last few weeks. Staff are to respond to pages within twenty (20) minutes, but they normally respond under ten (10) minutes. Residents interviewed stated it can take any where from fifteen (15) to thirty (30) minutes. Staff interviews indicated that staff usually respond to resident’s call buttons right away unless they are with another resident. If staff forget to clear the call button after they respond they are to document that in the shift reports. Based upon the information obtained during investigation, the above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted a copy of the report and appeal rights were left at the facility.