Complaint Investigation Report

The complaint alleges that staff did not prevent Resident R1 from sustaining a fracture while in care.

Review of the records and interviews of the ED and staff revealed that R1 was independent and only needed assistance using the restroom at night. R1 was not known to wander during the day or at night. When R1 fell outside on the patio and sustained a right leg fracture on 12/23/2023, it was the first time R1 tried to leave the facility at night.

The complaint alleges that Facility is not adequately staffed to meet the needs of the residents in care.

Review of the records and interviews of the ED and staff revealed that R1 was a fall risk and was placed on two-hour checks to make sure that she was in her room and safe. Interviews with overnight staff S1, S2, and S3 revealed that they responded to the door alarm in R1’s room within 5 minutes, in accordance with the facility’s policy.

The complaint alleges that staff are not serving nutritious meals to residents.

Review of the restaurant menu and interviews of 2 residents, R4 and R5, revealed that the facility staff are serving nutritious meals to the residents.

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 allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.