Complaint Investigation Report

The investigation revealed the following:

Allegation 1: Resident sustained an unexplained fracture while in care.

It was alleged that a Resident sustained an unexplained fracture due to lack of supervision or negligence while residing at the facility. On 07/08/2025 at 10:40 AM, LPA interviewed A1 (Administrator). A1 denied the allegation and stated that R6 injury was reported promptly to the physician, the responsible party was notified, and the incident occurred when staff was not present in the immediate area, but there were no signs of abuse or neglect. A1 indicated that staff follow protocol, and the resident had a history of unsteady gait despite using a walker. On the date of the incident, R6 was sitting in his wheelchair at the dining table. Between 9:30 AM and 10:15 AM, LPA interviewed 2 staff regarding the allegation: 2 of 2 staff denied the allegation. Between 8:35 AM - 9:13 AM, LPA interviewed 3 residents: 2 out of 3 residents denied the allegation. 1 out of 3 residents was unaware of the allegation.

LPA conducted a records review on 06/25/2025, between the hours of 11:06 AM - 11:45 AM & 08/07/2025, between the hours of 9:20am - 9:30am and observed the following: The LIC 624: Unusual Incident/Injury Report dated 03/28/2025, R6 was sitting around the table when S1 heard a sound coming from the dining room and S1 witnessed R6 on the floor. Staff called 911 and notified the assistant administrator. The assistant administrator called R6's POA who was able to come to the facility at the same time as paramedics. POA insisted that R6 was okay and did not need transportation to the hospital. Paramedics agreed and he was not transported to the hospital. The resident was admitted to the facility on 06/18/2024. According to the Physician’s Report, the resident has been diagnosed with dementia, is non-ambulatory, and requires assistance with grooming, bathing, and feeding.