complaint·March 19, 2026

Interviews revealed that S2 called S1 on the walkie talkie told them about the incident. Camera footage showed S1 arrived at the room at 5:31am, then S1 called the lead med tech @5:37am to inform them of the incident. Interviews revealed the lead med tech told them not to move the resident, grab R1s medical book, to call 911 and call the hospital to let them know R1 was coming and that they needed a sitter. Interviews revealed that S1 relayed the message of not moving R1 to S2. Interviews revealed S1 went to the front of the facility to grab the book and make the call to 911. Interviews revealed when S1 returned to the R1s room, S1 observed R1 had been moved, showered and was dressed. Interviews revealed that camera footage shows S2 requesting towels from another staff despite R1 showing complaints of pain while their shoulder was popped out. Interviews revealed the company policy states that rounds are to be conducted every 2 hours. It also states in the event of a witnessed or unwitnessed fall, where a resident is expressing pain, the resident must not be moved and 911 must be called immediately. EMS personnel arrived on scene at 6:03 am and took R1 to the hospital. Records reviewed revealed R1 was diagnosed with resident sustained a right humerus fracture and a small subdural hematoma. (The report shows resident suffered a right fracture humerus back in January 2025 as well and at that time they were treated non surgically) and R1 was discharged to a skilled nursing facility from the hospital. Interviews revealed the staff were written up for their actions on 08/13/2026. Interviews revealed that S1 quit after their write up and S2 was terminated on 08/20/2025 due to failure to conduct resident rounds every two hours, as required. Video footage indicated rounds were completed at 11:11 pm., 3:49 am., and 5:28 am., falling short of the mandated schedule. Improper handling of a resident following an unwitnessed fall. Despite the resident expressing pain and showing signs of a displaced shoulder, S2 proceeded to move, shower, and dress resident prior to EMT arrival and failure to adhere to emergency protocol. (The Company policy clearly states that in the event of a witnessed or unwitnessed fall accompanied by pain, the resident must not be moved and 911 must be called immediately. These actions represent a serious breach of our standards of care and safety protocols and compromise the well-being of our residents). Based on interviews, and records review, the allegation is valid, and the preponderance of the evidence has been met. An exit interview was conducted with Susan O'Shaughnessy, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.