Complaint Investigation Report

Regarding the allegation: Resident sustained multiple falls due to lack of supervision. It is alleged that resident #1 (R1) had two (2) falls since they moved in. Let it be noted that R1 moved in on 04/04/25 and had only one (1) fall on 07/06/25. R1 had one (1) fall on July 06, 2025 that was confirmed by Staff #1 (S1)’s interview with LPA. LPA reviewed the Unusual Incident/Injury Report that was sent to Community Care Licensing Department on 07/09/25. R1 had fallen on 07/06/25 and was sent to the hospital also notification was sent to R1’s Power of Attorney and doctor. LPA could not interview R1 because R1 no longer resided at the facility. LPA obtained R1's admission agreement, Physician's Report and Service Plan. Furthermore, because of R1's fall on 07/06/25, R1 was put on safety checks four (4) times per shift on 07/08/25 for extra precaution. Therefore, based on the record reviews and interviews conducted, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Facility staff did not ensure that resident has an appropriate bed. It is alleged that that the facility has not provided an appropriate bed for the resident #1 (R1) since they moved in and R1 has been sleeping on a "cot" for 2 weeks. During LPA’s interview with Staff #1 (S1) confirmed that R1 had two (2) beds since their stay at the facility. One (1) was provided by the facility themselves and the other was provided by home health. Let it be noted that R1 was under home health care at the time. LPA could not interview R1 because R1 no longer resided at the facility. During LPA’s physical tour, LPA observed seven (7) random bedrooms that had appropriate beds-beds with bedspreads, mattresses and headboards. LPA interviewed seven (7) residents that confirmed they have always had individual beds and not “cots”. Therefore, based on the record reviews, physical tour and interviews conducted, the allegation is UNSUBSTANTIATED at this time.

Regarding the allegation: Facility staff did not shower resident. It is alleged that Resident #1 (R1) did not shower for two (2) weeks. During LPA’s interview with Staff #1 (S1) and Staff #2 (S2) they confirmed that all residents shower twice a week. LPA could not interview R1 because R1 no longer resided at the facility. LPA interviewed seven (7) residents. Three (3) out of the seven (7) residents that were interviewed need help showering and confirmed they shower twice a week. Therefore, based on the record reviews and interviews conducted, the allegation is UNSUBSTANTIATED at this time.