Complaint Investigation Report

LPA reviewed assessments and R1’s physician’s report (dated 11/18/2024) which state R1 was a standby assist for bathing and dressing; and indicates that R1 was considered non-ambulatory and used a walker and wheelchair; able to independently transfer to and from bed. Internal care notes indicate that on 1/21/2026 R1’s responsible party was contacted to discuss R1 needing a higher level of care due to changes in cognition, not ambulatory status.

Staffing records indicate that on 1/25/2026, the date of R1’s reported fall, there were two (2)med. techs and two (2)care staff scheduled for the AM and PM shifts. Incident Report submitted to the Department indicates that on 1/25/2026 R1 had an unwitnessed fall. Complainant states it was witnessed by a caregiver, who was helping R1 with their walker. Based on LPA’s record review and interviews, prior to R1’s fall of 1/25/2026, R1 was considered a standby assist to help with bathing and dressing/activities of daily living (ADLs), not ambulation.

The complaint alleges that the facility did not dispense medication as prescribed. This allegation investigated under complaint #21 AS 20260204155138 and #21 AS 20260225125201.

Based on a review of records, prior to the fall of 1/25/2026, R1 was a standby assist for certain ADLs and able to access and use their walker and wheelchair independently. Therefore, the allegation that “Due to lack of staffing proper lifting practices were not being implemented, resulting in resident being injured” is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.