Complaint Investigation Report

The investigation revealed the following: Regarding the allegation “ Staff are not addressing resident fall risk ,” it was reported that R1 has a history of multiple nighttime falls. Three (3) out of three (3) staff interviewed denied the allegation. S1 stated R1 had not sustained any falls while at the facility. S1 stated R1 would tell S1 about their night and would have mentioned if they had fallen. S1 stated caregivers report to each other what happened during the previous shifts so that the incoming staff were aware if anything had happened. LPA reviewed staff notes dated 05/28/26-06/30/26, staff did not mention any falls for R1. S2 stated no falls had been reported by caregivers. S3 stated they were nighttime staff. S3 stated R1 had been there for about one (1) month and had not sustained any falls. S3 stated R1 used a wheelchair and would ask for assistance when needed. S3 stated R1 would talk about their day and did not mention any falls. LPA interviewed R2. R2 stated they were not aware of any falls and staff always help.

Regarding the allegation “ Staff are not administering medication as prescribed, ” it was reported that R1 intermittently takes their medications only when they feel they need them. Three (3) out of three (3) staff interviewed denied the allegation. S1 stated R1 never refused medication. S1 stated there were medications that were not given due to reading of R1’s vitals and medication not being necessary (per doctor’s prescription) but R1 always cooperated when assisted with medication administration. S2 stated R1 always took their medications. S3 stated they did not assist R1 with medication administration, but caregiver notes did not mention R1 refusing medication.

Based on interviews and record review, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to Administrator Humberto Santamaria.