Complaint Investigation Report

Records obtained documented that C1 had a history of falls, sustaining at least four known falls between July 2024 through October 2025. Records did not show that the facility completed a timely reappraisal nor implemented updated fall-risk interventions after each fall. After C1’s fall in October 2025, the facility and C1’s service coordinator discussed possible fall-risk interventions. These interventions included the use of a walker, wheelchair, helmet, physical therapy referral, fall-risk assessment, and staff supervision when C1 used the restroom or changed clothing. However, interviews with three facility staff members and one service coordinator indicated that these interventions had not been fully implemented prior to C1’s fall on November 5, 2025. Interviews with staff report that two of the four clients require full assistance with activities of daily living. Despite this, facility staff also reported that the night shift was staffed with one caregiver because clients were generally expected to be asleep during the night despite C1 requiring supervision when using the restroom. In addition, the facility’s night-check practice was described as periodic checks throughout the night; however, the Administrator stated that staff did not maintain a physical log documenting those checks.

During the night of November 5th, 2025, Direct Support Professional (DSP1) was the only staff on duty and was responsible for overnight monitoring and periodic checks. DSP1 reported they were in the restroom when they heard C1 calling for help and found C1 lying on the bathroom floor with C1's walker/rollator nearby. DSP1 stated C1 had gone to the restroom independently and had not requested assistance before entering the restroom. DSP1 placed a pillow under C1's neck for support and called 911. C1 was transported to the hospital where they were admitted.

Per hospital medical records, C1 sustained blunt trauma, spinal injury, and a fracture, and required intubation due to acute respiratory failure requiring surgery and ongoing intensive medical care. C1 was unable to move all four extremities. {****CONTINUE 9099C***}