Complaint Investigation Report

The needs and services plan also states that R1 functions independently with all activities of daily living. This plan was signed by facility staff and R1. LPA reviewed an incident report dated December 1, 2025, stating that on November 27, 2025, R1 had an unwitnessed fall and was found by staff on the floor. Staff called 911 and R1 was taken to the hospital. LPA reviewed daily assignment lists for staff to assist with residents activities of daily living with high fall risk indications. R1 was not observed on the lists dated November 23, 2025, through November 27, 2025, as a resident needing assistance or a fall risk. LPA reviewed discharge documentation for R1 dated January 23, 2026, stating that R1 has a history of a fall and was stable and ready to discharge back to the facility. The documentation did not indicate how long R1 was left on the floor.

LPA interviewed eleven residents including R1. Eight of eleven residents informed LPA that they have no problem with the staff assisting them. Eight of eleven residents informed LPA that the staff will come when they need assistance in a timely manner, including R1. Three of eleven residents did not confirm or deny the allegation. Two of eleven residents informed LPA that staff will come around and check on residents throughout the day and night even when they have not called for assistance.

R1 denied the allegation and stated that they did not think to call for assistance but is confident that if they did, staff would have come.

LPA interviewed six staff. One of six staff informed LPA they found R1 on the floor and called for assistance immediately. Six of six staff did not know how long R1 had been on the floor. Two of six staff informed LPA that R1 is independent and able to ambulate on their own.

LPA reviewed an in service staff training that was conducted on April 22, 2026, for four of six staff on the topic of fall precautions. One of six staff does not provide care and one of six staff conducted the in service training.

Based on information gathered and interviews conducted, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was left at the facility.