complaint·August 14, 2025

Regarding the allegation: 1.) Due to lack of supervision, resident was pushed by another resident causing the resident to fall. It was alleged that Resident #1 (R1) was pushed by another resident (name unknown) causing R1 to fall. Interviews conducted with staff on 11/20/2024 and 02/25/2025 denied witnessing another resident push R1. However, one (1) out of fifteen (15) staff interviewed, Staff #1 (S1) stated that they have witnessed R1 being pushed by Resident #2 (R2) causing R1 to fall. S1 stated that they do not recall when this occurred and that they reported the incident to management. Per record review, there was no documentation of the alleged incident. Interview with the ED denied the allegation and stated that it is rare that residents push each other. The ED explained that care staff are trained to redirect residents when a resident is aggressive. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Regarding the allegation: 2.) Due to staff neglect, resident fell while being changed by staff causing the resident to sustain a bruise. It was alleged that Resident #1 (R1) fell while being changed by staff causing a bruise on R1’s face in November 2024. Per Unusual Incident/ Injury Report dated 11/10/2024, on 11/06/2024, R1 fell off R1’s bed as two (2) caregivers were assisting R1 with dressing. Per the report, 911 was called and R1 was transported to the Emergency Room (ER). Per hospital records, R1 was admitted to the hospital from 11/06/2024 with the reason for admission listed as “fall and subdural hematoma” and was discharged on 11/12/2024. Per interviews with staff and record review, R1 was transferred and admitted to a Skilled Nursing Facility (SNF) on 11/12/2024 with the principal diagnosis of “Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter.” Per record review, R1 had a previous fall on 10/15/2024 in which R1 was hospitalized and had computed tomography (CT) scans due to R1 having a facial contusion from the fall. R1’s fall from October 2024 was the source of R1’s facial bruise, not from R1’s fall on November 6, 2024. Interviews with staff revealed that R1 would often make themselves fall or be uncooperative while staff assisted with R1’s Activities of Daily Living (ADL). The interview with the ED revealed that staff have been retrained on ADLs and in overall resident care. Concerns and deficiencies regarding R1’s care are being addressed with a Case Management Deficiencies report. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation as R1 already had a facial bruise from a previous fall. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.