Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff did not assist resident with ambulating

It was alleged that facility staff failed to assist a resident for days at a time and that prior to 12/21/2025 the resident had not been out of bed since 12/16/2025. It was also alleged that staff told resident they cannot get the resident out of bed.

On 01/07/2026 between the hours of 9:38am -10:01am, LPA interviewed the Administrator in regard to the allegation. A1 denied the allegation and stated caregivers routinely check on residents in the morning and offer assistance getting out of bed. A1 stated that residents are assisted based on their willingness and ability to transfer safely. Additional caregivers assist when a two- or three-person transfer is required, and the nurse is contacted if a resident is in pain. A1 acknowledged awareness of a R10 remaining in bed prior to 12/21/2025 but denied that any caregiver refused to assist a resident without reason.

On 12/29/2025 between the hours of 9:43am - 4:00pm, the LPA interviewed 10 staff regarding the allegation. 9 of 10 staff denied the allegation and stated resident who need assistance with ambulation will help upon request and or following the directives of the residents care plan. 1 of 10 staff did not confirm nor deny the allegation and stated due to R10 have a neck injury it was advised resident be on bed rest for 3-4 days.

On 12/29/2025, between the hours of 11:24am - 2:26pm, the LPA interviewed 10 residents regarding the allegation. 1 of 10 residents confirmed the allegation and stated they are suppose to get help from staff when they want to get out of bed but that doesn't happen ; staff would take too long to assist them so they would get themselves out of bed. 9 of 10 residents denied the allegation. 3 of 9 residents stated staff will come by in the morning to assist with transferring, while 6 of 9 residents independently get themselves out of bed.

On 01/07/2026 between the hours of 8:40am - 8:45am, LPA conducted a records review and observed the following: the LIC 625 Appraisal/Needs & Service Plan (dated 09/23/2025) stated for R10 one caregiver reported that two of caregivers are not able to transfer R10 due to an unintentional fall as a result of the resident's weight. Caregivers noted R10 needs at least 3 caregivers to assist him with his ADLs and transfer.

Based on information gathered through interviews and record reviews, there is not enough evidence to support 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 allegation is UNSUBSTANTIATED.

Investigation findings continues on LIC 9099-C