Complaint Investigation Report

The investigation revealed the following:

Allegation: “Staff do not answer residents calls for assistance resulting in resident falling”, it is being alleged that on 10/24/2025, R1 had an un-witnessed fall due to staff not answering their calls for assistance. Interviews conducted with R1 to R7 revealed the following: R1’s interview was inconclusive; 3 out of 7 residents indicated that they have never fallen at the facility; 3 out of 7 residents indicated that staff assist them when they need assistance. Interviews conducted with S1 to S7 indicated the following: 7 out of 7 staff denied the allegation, furthermore, staff indicated that they assist residents when they call out for help and when they press the call button. R1’s records reviewed revealed the following: R1 is diagnosed with a mild cognitive impairment and experiences episodes of confusion according to the Physicians Report dated 06/22/2025. Unusual Incident Report dated 10/24/2025, stated that on 10/24/2025 R1 “slipped while trying to get out of bed.” Progress Notes indicate that on 10/24/2025 at around 11:10 PM, R1 had an un-witnessed fall and was sent out thru non-emergency ambulance on 10/25/2025. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. 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.

An exit interview was conducted, and a copy of this report was left with the Administrator, Joel Niblett.