Complaint Investigation Report

Interview with S1 revealed when they transferred R1 from their reclining chair to their bed, R1’s legs gave out. S1 “helped them to the floor”. R1 was not injured. Interview with Staff #2 (S2) at 9:30 a.m. on 12/02/25 revealed they heard S1 request help from R1’s room. S2 found R1 on the floor and assisted them into bed with S1. S2 told S1 that R1 does not use a walker, only a wheelchair. Review of R1’s medical assessment revealed they are nonambulatory, wheelchair-bound, and require assistance with transferring. Review if R1’s care plan revealed they were at “significant risk for falls”. Review of video footage from R1’s room revealed S1 assisted R1 in standing from their chair at 1:45 p.m. on 11/20/25. S1 placed R1’s walker in front of them and pushed their backside to assist them standing. S1 then walked about five (05) steps with R1. As R1 began falling, S1 held and lifted the back of R1’s pants to ease their fall. R1 then fell to their knees with their hands still on their walker. S2 arrived at 1:47 p.m. S2 informed S1 that R1 only uses their walker once per day and not for transfers. Based on interviews, record review, and video review, staff did not provide proper transfer assistance to R1, resulting in their fall. Therefore, the allegation is deemed SUBSTANTIATED at this time.

Regarding the allegation "Licensee did not properly train staff" it was alleged staff were not sufficiently trained to care for R1. Interview with S1 revealed they were not trained on R1’s care plan. S1 was not R1’s regular caregiver and provided care to R1 because of the regular caregiver’s absence. Interview with S2 revealed they “could not remember the last time” the facility provided training. Record review of caregiver files revealed the training provided to all caregivers in 2025 by the facility was insufficient in both hours and content. The facility did not provide caregivers with sufficient training until February 2026. Based on interviews and record review, the licensee did not properly train staff. Therefore, the allegation is deemed SUBSTANTIATED at this time.

No immediate health or safety concerns observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.