Complaint Investigation Report

LPA's interview with R1's friend Resident #3 (R3) today at 11:39 AM, revealed that R1 always go around with a walker with R3 all the time especially during mealtime and did not witness R1 falling at any time. R3 did not witness R1's fall on 01/30/25. LPA's interview with the first staff who saw R1 on the floor revealed that the staff saw R1 walking without a walker heading to the direction leading to the dining room on the first floor which is unusual because R1 always go down in the main dining room in the lobby floor. Staff passed by R1 but when staff came back after delivering tray to the residents on the first floor, staff saw R1 on the floor and called other staff to assist R1. R1 was assessed by the facility Resident Care Director who is also a Licensed Vocational Nurse (LVN), put on a wheelchair and applied first aid. R1's family member was informed who eventually brought R1 to the hospital for further evaluation. LPA’s interview with the administrator on 02/13/25 at 12:35 PM, revealed that R1 usually walk with a walker but during the incident R1 was not using R1’s walker, the Administrator added that R1 may have forgotten that R1 was using a walker to ambulate as R1 has a Dementia diagnosis.

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.