Complaint Investigation Report

Review of R1’s medical assessment dated 07/23/2024 stated that R1 had a diagnosis of Osteoporosis and Dementia, was non-ambulatory, and was able to communicate their needs.

Review of R1’s Service Plan dated 02/07/2025 stated that R1 utilized a walker, was able to express pain and communicate effectively. It also stated that R1 was a high risk for falls.

Review of R1’s Service Plan dated 01/22/2026 stated that R1 had mild impairment and had some difficulty communicating or receiving information. It also stated that R1 utilized a walker, was able to express pain and was a low risk for falls.

Review of R1’s Service Plan dated 03/08/2026 stated that R1 had mild impairment, could express pain, and had frequent pain and/or discomfort. It also stated that R1 utilized a walker and was a high risk for falls. This plan also stated that to ease R1’s back pain staff were to provide medication and ensure that R1 could rest, sit in a comfortable position, and avoid standing or walking for too long.

Review of Incident Report dated 03/23/2026, stated that on 03/12/2026, R1 was taken to the hospital by family for lower back and leg pain. Per report, R1 was suspected to have a urinary tract infection (UTI) and was receiving antibiotics as treatment.

Facility documents also showed that facility faxed R1's primary physician on 03/10/2026 to notify them of the un-witnessed fall and that there were no injuries noted for R1.

Interview conducted with Witness 1 (W1) stated that R1 transitioned from the facility’s assisted living to their memory care community in February 2026. Per W1, R1 was experiencing pain prior to transitioning to memory care. W1 was unable to determine if there was a change in how R1 was walking prior to being sent to the hospital. W1 stated that R1 used to use a walker and is currently using a wheelchair while they receives physical therapy to work on their gait.

Interview conducted with Witness 2 (W2) stated that prior to moving to the facility’s memory care, R1 was complaining of back pain. W2 was unable to determine if there was a change in how R1 was walking prior to being sent to the hospital. W2 stated that R1 used to use a walker and is currently using a wheelchair while they receive physical therapy to work on their gait.

Interview conducted with Staff Member 1 (S1) stated that R1 usually used a wheelchair and has a history of asking for pain medication for their back. Per S1, R1 is able to communicate where they have pain and will point to the area.

Review of R1’s caregiver end of shift notes for March 2026 was conducted. Notes for 03/10/2026 – 03/11/2026 did not