Complaint Investigation Report

with staff, residents, and other relevant parties on the following dates: 05/28/2025, 06/25/2025, 06/26/2025, 07/22/2025, 07/31/2025, 08/01/2025, 08/18/2025, 09/23/2025, 09/24/2025, and 09/25/2025. Investigator Real also reviewed copies of R1’s medical records, including but not limited to facility medical documents, physician’s documents and outside medical provider records. LPA then reviewed all information obtained by Investigator Real. The following was then determined:

Allegation “Neglect/Lack of supervision: facility employees failed to provide an appropriate level of supervision resulting in R1 falling multiple times and sustaining a fracture:”

The complaint alleges that R1 fell multiple times while at the facility which resulted in R1 sustaining a hip fracture. Interviews and documents reviewed revealed that R1 moved into the facility on 05/19/2023, had a diagnosis of dementia, and was ambulatory at that time. Staff interviewed stated that R1 was very active and walked around the facility’s Memory Care unit often. Incident reports reviewed revealed that R1 had an unwitnessed fall on 08/25/2024 and the fall resulted in no injury. Although no incident report was able to be located, interview and hospital records revealed R1 fell again on 03/04/2025 and was transported to the emergency department for further evaluation. This fall resulted in no injury and R1 returned to the facility the same day. Hospital records and staff interview revealed on 03/08/2025, R1 fell in the common area of the Memory Care unit. R1 was transported to the emergency department, where R1 was diagnosed with a closed comminuted intertrochanteric fracture of the proximal end of the left femur. R1 remained hospitalized for treatment prior to returning to the facility on 03/11/2025. Interview revealed that following R1’s hospitalization, R1 was placed on 15-minute checks, however no documentation was provided to indicate 15-minute checks were completed. Staff interviewed stated the Memory Care unit was understaffed frequently, leaving two (2) caregivers for 20-25 residents with dementia diagnoses. Staff interviews revealed when understaffed, staff were unable to conduct 15-minute checks for the ten (10) residents that required such additional supervision. Staff stated when checks are unable to be completed, the 15-minute check forms were left blank. Incident report and hospital records revealed R1 had another fall on 04/24/2025. Activity staff found R1 on the floor in their room around 05:15PM, R1 appeared to be in pain. R1 was transported to the emergency room, where R1 was diagnosed with an acute periprosthetic fracture (a broken bone that occurs around an orthopedic implant) about the left femoral stem with angulation and an acute