Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff does not assist the resident with ambulation.

LPA Bunker interviewed Staff #1–#4 (S1–S4). All four staff members (4 out of 4) stated that staff assist residents who are non-ambulatory and require support. S1–S4 reported that the resident does not require assistance transferring from the wheelchair to the bed, and stated that staff are always available to assist if needed. Staff stated that the resident is not a fall risk, and there is nothing in the resident’s medical records indicating a history of falls. 4 out of 4 staff members denied that the resident ever fell thirty-five times and stated that the resident had no injuries or bruises related to falls. 4 out of 4 staff members reported that the facility conducts rounds every two hours, or more frequently when safety risks are higher, and that no staff witnessed or heard the resident fall. S1-S4 also stated that the resident was not lying on the floor. 4 out of 4 staff members stated that the staff are always available to help. All four staff (4 out of 4) denied the allegation.

LPA Bunker interviewed Residents #1–#6 (R1–R6). All six residents (6 out of 6) stated that staff assist residents who are non-ambulatory and need help. 6 out of 6 residents reported they had not witnessed any residents falling and stated that residents do not fall at the facility. All residents confirmed that staff are always available to assist and that their daily care needs are being met. 6 out of 6 residents stated they are happy living at the facility and have no concerns. R1–R6 denied the allegation.

W1 stated that the resident, who ambulates via wheelchair, reported needing assistance transferring from the wheelchair to the bed. W1 reported that the resident claimed to have fallen thirty-five times but had not sustained any injuries or bruises from the alleged falls. W1 also stated that the resident could not provide dates or times when these falls occurred, and there were no witnesses to verify the incidents. W1 stated that the resident claimed they had been lying on the floor because staff allegedly refused to help. W1 stated that the resident reported there were no witnesses who ever saw the resident on the floor.

The Department reviewed the resident’s Physician’s Report (dated 10/01/2024), Appraisal/Needs and Services Plan (dated 07/15/2025), Functional Capability Assessment (dated 07/15/2025), and Pre-placement Appraisal Information (dated 07/15/2025). There was no indication that the resident had a history of falls, was considered a fall risk, or required assistance transferring from the wheelchair to the bed. Documentation reflects that the resident uses a wheelchair and is able to get in and out unassisted.