Complaint Investigation Report

This report supersedes the report created 7/25/25 and the findings will remain unchanged.

Allegation: Allegation: Resident sustained an unexplained injury while in care.

The details of the complaint alleged that (C#1) sustained unexplained injuries while in care.

On June 25, 2025, at approximately 10:00 AM, LPA Iniguez reviewed records and observed the hospitalization discharge papers for (C#1), dated April 21, 2025. LPA Iniguez noted that there were no indications of injuries sustained by (C#1) due to staff negligence. Additionally, LPA Iniguez received an email from a hospital social worker. In the email, they stated that no notes indicate (C#1) signs of neglect. Moreover, LPA Iniguez observed Copies of facility staff training regarding clients' rights, dated May 14, 2025, and a copy of staff training regarding the importance of observing clients' seizures. The training indicates that facility staff will record clients' seizure episodes, including their duration and techniques used to prevent injury during these events.

On April 22, 2025, at approximately 2:00 PM, during an interview with the Administrator (A#1), he states that on the morning of April 21, 2025, (C#1) looked disoriented and not themselves, also, (C#1) did not have signs of injuries on them. (A#1) called we informed (C#1) 's placement agency, their physician, and (C#1) 's representatives. (C#1) was admitted, and the hospital test result showed (C#1) sustained a Traumatic Brain Injury (TBI). (A#1) stated that neither he nor the facility staff observed (C#1) sustaining a fall or having a seizure that might cause their injury.