complaint·April 23, 2026

Allegation: Staff neglect resulted in a resident sustaining a fracture due to a fall. It is alleged that R1 had a fall that could have been prevented but the evening staff were inattentive and did not take the appropriate actions to make sure R1 had adequate assistance. Based on records review, R1 was admitted to the facility on March 24, 2024. R1 is non-ambulatory and is unable to independently transfer to and from bed. R1 needs full assistance with self-care, besides feeding self. R1 is confused/disoriented; however, R1 is able to follow instructions and communicate needs. Since admission, R1 had the first fall in January 2025, where a facility staff found R1 sitting on the floor next to their bed. No injuries were reported from this incident. Based on progress notes dated February 28, 2025, at 8:49 PM, staff noted R1 had a second unwitnessed fall. During the investigation, interviews were conducted where six staff out of six staff denied the allegation. Based on two out of six staff interviews, on February 28, 2025, R1 got up from bed in order to close the door but fell. S2 stated that R1 was found by a staff on the floor, upright, leaning against their bed, while conducting a routine resident check. Record review indicates immediately following the incident, R1 was given a full body assessment, and PRN medication was administered but it was ineffective. Subsequently, R1 expressed pain and requested to contact their son and be taken to the hospital. S6 called 911 and R1 was taken to the hospital. Interviews were conducted with residents. R1 stated that they noticed the door was open, attempted to get out of bed to close the door and subsequently fell. R1 acknowledged that they did not request staff assistance and did not utilize their wheelchair or walker when attempting to close the door. Additionally, two resident interviews indicated that staff are attentive to resident care, and both residents denied the allegation. The evidence indicates that R1 did not request staff assistance and did not utilize their wheelchair or walker, which resulted in an unwitnessed fall, and subsequent injury. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Continued on LIC9099C Allegation: Facility is understaffed. It is alleged the facility has cut staff hours and retaliates against caregivers, so they are not fully staffed. Based on records reviewed, the facility had twenty-three staff assigned to provide care to residents in the memory care unit, according to the Staff Schedule dated February 2025. On February 28, 2025, there were four staff assigned to the first shift, and three staff assigned to both the second shift and NOC shift. Based on the LPA’s observations during visits conducted on March 16, 2025, and August 15, 2025, there were four staff on duty providing care and supervision to residents in the memory care unit and no staffing concerns were observed. Based on interviews conducted, six out of six staff and three out of three residents denied the allegation. Two out of two staff stated that when staff called out, the facility would seek coverage by offering overtime to staff from other shifts, contacting part-time staff, or utilizing an outside agency. Three out of six staff stated there was sufficient staffing in the memory care unit and that residents were routinely checked at least once per hour or more often. Based on the information gathered, there is insufficient evidence to corroborate the allegation. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations that staff neglect resulted in a resident sustaining a fracture due to a fall and facility is understaffed. 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 provided to Administrator Austin Morris.