Complaint Investigation Report

Department record review and interviews revealed that on 11/25/2025 at approximately 1420 hours, staff found R1 on the floor in R1’s room next to a recliner. R1 reported standing up from the chair, losing balance, and falling. R1 stated that R1 hit the back of the head and experienced pain. Records further reveal R1 was transported to the hospital for evaluation and returned later the same day.

Further records and interviews review revealed that on 11/29/2025 at approximately 0211 hours, staff found R1 sitting in a wheelchair holding the right arm and appearing to be in pain. When staff asked R1 if a fall occurred, R1 denied falling. Staff observed bruising and swelling to R1’s right arm that increased over time and arranged for R1 to be transported out of the facility for medical evaluation. Records review and staff interviews revealed R1 was last observed in bed at 2220 hours and that routine rounds were conducted at 0200 hours. Shortly thereafter, R1 was heard awake and found sitting in the wheelchair. No staff witnessed a fall, and staff could not determine how the injury occurred. Outside-source medical records confirmed R1 sustained a right arm fracture and presented with significant pain. Records did not establish the mechanism of injury.

Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Karinna Topete, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.