Complaint Investigation Report

To investigate these allegations, the Department conducted an onsite facility inspection, reviewed facility and medical records, reviewed incident reports, and conducted interviews with facility management staff, direct care staff, and outside sources. The Department also reviewed medical provider records and hospital records covering the relevant time period. Through these investigative methods, the Department assessed the facility’s compliance with applicable laws and regulations and evaluated the care and supervision provided to R1.

According to the complaint, staff failed to provide adequate supervision to R1, resulting in repeated falls, including a bathroom fall involving spilled mouthwash and a courtyard fall where R1 was found outside without staff present. It was further alleged that R1 sustained serious injuries including a cervical fracture and head injuries requiring emergency medical evaluation and treatment.

A review of R1’s facility and medical records showed R1 was admitted to the facility in 2021 and had diagnoses including dementia with cognitive impairment and unsteady gait. Records documented fall risk, wandering behavior, and need for assistance with activities of daily living, including bathing, dressing, toileting, and transfers.

Medical assessments and physician records documented that R1 had an unsteady gait and was considered a fall risk. Records showed R1 sustained a cervical spine fracture in April 2025 and thereafter required use of a cervical collar and ongoing fall precautions. Physician follow-up notes repeatedly documented fall risk, neck injury, and continued need for monitoring and protective interventions.

Facility Needs and Services Plans reviewed during the investigation documented that R1 was a high fall risk, required supervision, and that staff were to monitor R1 for changes in gait and balance, ensure use of assistive devices and cervical collar, supervise due to wandering behavior, and be aware of R1’s whereabouts at all times.