Complaint Investigation Report

Regarding the allegation: Due to improper transfer assistance, the resident experienced a fall incident. It is being alleged that while staff were transferring resident #1 (R1), R1 fell and broke their right hip. LPA obtained an Unusual Incident Report on 12/31/25, where it says R1 fell while in their room and 911 along with their spouse were notified immediately. LPA interviewed three (3) staff that have confirmed R1 fell in their room without any assistance. Staff #1 (S1) confirmed that they heard a loud noise and ran to R1’s room but R1 was already on the floor. Staff #2 (S2) confirmed they were helping another resident when S1 requested for their assistance with R1 to help get R1 up from the floor. S1 and S2 immediately called the administrator and 911 was called. In addition, staff reported that "R1 had dementia, had a walker but at times R1 would forget to ask for help and use the walker and would get up on their own." LPA spoke to R1’s spouse and R1’s spouse confirmed that R1 had dementia was fragile and had mobility problems and that the facility immediately called them when R1 fell and R1 was also transferred to a hospital that day. R1’s spouse also confirmed that "R1 was transferred to a skilled nursing a couple days after they went to the hospital and does not blame the facility for what happened to R1 because R1 was already deteriorating at a fast pace when R1 was taken to the facility the beginning of December 2025." Furthermore, LPA interviewed one (1) out of 3 (three) residents that confirmed they were there when R1 fell in their room, there was three (3) staff present and the ambulance came for R1. Therefore, based on the record reviews and interviews conducted the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff did not ensure resident was fed resulting in extreme weight loss. It is being alleged that resident #1 (R1) was losing weight prior to moving to the above facility and lost an additional 10-15lbs while at the facility. This allegation can be referenced to control number-31-AS-20251230162335. It was recently investigated on 01/07/26. R1's medical assessment on 12/03/25, shows that R1 weighed 134llbs and R1's nurse visit on 12/16/25 (under Palliative Care) indicated that R1 weighed 150lbs and actually gained weight while at the facility. Let it be noted, R1 was transferred to a hospital on 12/30/25 and did not return to the above facility. Therefore, based on the record review and interviews conducted the allegation is UNSUBSTANTIATED at this time.

An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.