Complaint·September 11, 2025

The complaint alleges that due to lack of supervision, R1 fell, resulting in hip fracture. LPA reviewed the incident report for the resident’s fall, which indicated that R1 “was seated in common area activity room with care staff present...staff observed [R1] to lose [their] balance and fall to the ground, care staff attempted to stop the fall, but [R1] continued to fall to the ground.” Interviews revealed that during the time of the incident, there were 3 (three) care staff working and 15 (fifteen) residents. Also present were a medication technician and a lead care manager. 1 (one) care staff was on their lunch break, leaving 2 (two) care staff directly supervising the 15 (fifteen) residents. 1 (one) resident had set off an alarm, leaving only Staff #1 (S1) present with the remaining residents. S1 was present in the common area, however was moving the laundry at the time they saw R1 up from their chair and ambulating. S1 stated they saw R1 fall, but they could not stop the fall. Record review revealed that R1 did not require 1:1 supervision and typically R1 did not attempt to stand on their own. Record review revealed that both R1’s physician’s report and R1’s individualized service plan state R1 is independent with transfers. Staff interviewed stated that usually staff would bring R1 their walker and verbally prompt R1 to stand. While staff stated R1 was capable of standing on their own, this was unusual behavior for R1. The family member interviewed indicated that after the fall, R1 was diagnosed with a hip fracture and a urinary tract infection (UTI.) Family member stated that it’s possible R1 was confused due to the UTI, which caused the resident to stand unassisted. Interviews with staff revealed that there are no residents in this memory care unit that require 1:1 supervision. Staff interviewed stated they can visually see residents in the common area when doing laundry; LPA confirmed the proximity of the laundry area to the area R1 was seated at the time of the incident. Although R1 did fall resulting in a hip fracture, R1 did not require direct supervision at all times and staff were present at the time of the incident. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Staff did not ensure adequate supervision was provided resulting in resident sustaining injury” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today’s report was provided.