complaint·March 5, 2026

A review of medical records and death certificate indicates that the hip fracture was not the immediate cause of R1’s death. Furthermore, it is unclear if the hip fracture was due to staff neglect. The evidence does not support the allegation; therefore, the allegation is Unsubstantiated. LPA investigated allegation, “Staff did not properly supervise residents who are a fall risk.” The department interviewed relevant parties and staff, and reviewed hospital and facility documentation. On 9/7/25 R1 was admitted to the hospital with a chief complaint of a fall and hip fracture. Prior to this fall, R1 sustained approximately four falls while in care which resulted in injuries such as head injury, black eye, ear laceration, and an injury to their arm. Administrator and staff were interviewed in which they stated they were doing all they could to prevent R1’s falls. R1 had access to a call button, half bed rails, and a bed sensor to prevent falls. Staff were also checking on R1 every 30 minutes or less. Although R1 sustained several falls, there is not enough evidence to support that staff did not properly supervise resident; therefore, the allegation is Unsubstantiated. LPA investigated allegation, “Staff did not provide resident with activities”. LPA interviewed staff and residents and toured the facility. Relevant party stated facility staff had an activity calendar posted however they never engaged R1 in any activities. LPA interviewed 3 staff in which they stated R1 enjoyed a variety of activities from puzzles, playing cards, walking and gardening. Administrator stated that R1 had a garden bed that they would garden in frequently. Administrator stated that not many residents want to participate in group activities, so they engage the residents with more of 1-on-1 activities. LPA toured the facility and observed different activities available for resident use. LPA interviewed a resident in which they stated they are not interested in activities provided. Due to the information gathered LPA finds allegation to be Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted and copy of report provided.