Complaint Investigation Report

Regarding the allegation of neglect resulting in serious bodily injury, R1 has a documented history of health conditions that increases risk of fractures and bone weakness. Interviews with outside source medical professionals reveal the rib injuries sustained by R1 (imaging conducted August 16th, 2024) were age indeterminate, meaning it was difficult to determine when they occurred. R1 was also a known fall risk, but staff interviews and file review of R1's records reveal staff were aware and took precautions to prevent and/or mitigate fall risk. Per staff interviews, R1 did not have any falls around the time alleged in the complaint (August 2024) nor did any staff interviewed recall R1 having any falls or being dropped during assisted transfers. File review of R1’s charting records during that time corroborate that there were no documented falls either. Interviews conducted with the staff fitting the description indicated in the allegation revealed that R1 was not assigned to those staff members for care and/or transfers. Interviews with residents indicated no concerns regarding their care and staff supervision.

Regarding the allegation of medications not being administered as prescribed, file review and interviews with staff and outside sources reveal that R1 requires routine breathing treatments for a health condition. File review of facility records indicate that R1’s treatments were given routinely from July 2024 through January 2025 with no issues. Staff interviews revealed procedures taken when administering this specific type of treatment (staying with resident for duration of treatment) as interviews revealed that residents will often try to remove equipment necessary for treatment. Multiple staff members interviewed recalled resident R1 and having to stay with them and supervise during treatments. Staff interviews revealed that that they felt there were enough staff to timely give out medications, however one (1) indicated that they felt they needed more staffing in the Assisted Living unit as there are more residents residing there. Interviews with residents and outside sources raised no concerns about medications or residents’ care. Resident interviews indicated they received their medications timely. Additionally, interviews with outside sources revealed that the facility notifies them of incidents or updates regarding their respective residents.

Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Associate Executive Director Spence to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.