Complaint Investigation Report

The Department conducted interviews with facility residents, staff, and witnesses. On 04/09/2026, LPA P. Manalo conducted additional interviews with staff, residents, and witnesses and obtained the following documents included but not limited to an updated staff roster, resident roster, and Personnel Report (LIC500).

Allegation: Lack of care and supervision resulted in resident sustaining a fracture.

It was alleged that lack of care and supervision resulted in resident sustaining a fracture. A review of facility’s resident notes dated 05/10/2024 showed that S1 found R1 sitting on the floor holding their head due to an unwitnessed fall during S1’s last rounds. A review of On Lok Fall Incident Report dated 05/10/2024 revealed that S1 immediately called 911 and R1 was transported to the hospital.

Interview conducted by the Department revealed that R1 was not a fall risk per W1. Interview with S1 revealed that R1 was able to walk on their own and would hardly use their assistive device when walking around the facility. S1 stated that when S1 was conducting their last rounds on 05/10/2024, S1 found R1 on the floor. S1 proceeded to call 911 and R1 was taken to the hospital. 3 of 3 staff members all stated that R1 was able to walk on their own independently. The Department obtained and reviewed an intake assessment dated 4/18/24 indicating that R1 was not a fall risk and could ambulate and transfer independently. The physician report dated 4/18/24 did not indicate a mobility concern nor that assistance was needed for this issue. The Department further found that there were no other falls preceding the incident of 5/10/24. No other corroborating evidence was obtained to support the allegation.

Based on the investigation, which included interviews and record reviews, the allegation that lack of care and supervision resulted in resident sustaining a fracture is unsubstantiated . Although the concern was reported, there is insufficient evidence to confirm the allegations. Records reviewed were consistent with interviews, and no corroborating evidence was obtained to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.