Complaint·October 30, 2025

Allegation: Staff did not ensure care and supervision was provided resulting in resident sustaining a hip fracture On 5/26/2025 Staff #1 (S1) was conducting the last rounds of their shift, when entering Resident #1 (R1s) bedroom. R1 informed staff they needed to go to the restroom. S1 assisted R1 out of bed and R1 had complaints of pain. S1 advised R1 to wait so they could get R1 checked out, but R1 refused, demanding they use the restroom. S1 walked R1 to the toilet, when R1 sat down on the toilet, they “screamed” in pain. S1 called a Med-Tech who had just come on shift for assistance. S1 and Med-Tech escorted R1 to a sofa in their room, sat them down and evaluated them. At this point R1 could not stand up. Several other staff members were interviewed, and they all recalled the same story. S1 escorted R1 to the toilet, R1 called out in pain, and S1 called for help, R1 was evaluated and sent out. No fall during the night was reported. R1 was diagnosed with a “right femoral head, neck fracture.” Several residents were interviewed. All residents interviewed had no complaints about the facility and enjoyed the care they received. R1 was interviewed but due to mild cognitive impairment, they were unable to provide a comment on what occurred. Based on the information obtained during this investigation, it is unknown how R1 sustained their injury. R1 does not require any special checks during the night and was checked on throughout the night, staff reported they were sleeping. Based on R1’s care needs the facility staff acted appropriately per policy. Based on this information, this allegation is UNSUBSTANTIATED . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.