Complaint Investigation Report

Allegation #1: Staff neglect resulting in resident sustaining multiple falls.

It is alleged that Resident #1 (R1) sustained multiple falls due to staff negligence. Reports indicate that (R1) experienced several falls over three months: November 2025, December 2025, and January 2026. These incidents were attributed to delays in the emergency call system when responding to (R1's) basic needs, which were not met promptly. Although no injuries were reported, it was noted that (R1's) limited mobility, combined with the lack of assistance, contributed to these falls. No additional details regarding this allegation have been provided.

On February 04, 2026, between 11:00 AM and 11:50 AM, the Department interviewed resident members identified as Resident #1 and Resident #2 (R1-R2). Two (2) out of two (2) cannot validate this claim that multiples falls were due to staff neglect in care.

(R1) expressed a desire for independence and preferred not to rely solely on care staff. (R1) often took care of basic needs independently. Although (R1) stated that the treatment received from staff was satisfactory, (R1) exhibited impatience and was reluctant to wait for assistance, which sometimes led to falls. Additionally, (R1) reported experiencing gait issues, which caused (R1) to bend low to the ground and end up on the floor. Staff documented these instances as falls, even though (R1) did not perceive them as falls -"I just couldn't get back up."

(R2) has frequently observed (R1) being assisted by care staff while in bed. After the care staff leaves, (R1) often becomes defiant and attempts to transfer to an assistive device independently. This behavior frequently results in slips and falls, leading (R1) to use the emergency call system for help instead of asking for assistance beforehand. (R2) stated that (R1) requires staff assistance and will receive it but prefers to work independently. Furthermore, (R2) mentioned that the care staff are responsive when dispatched via the emergency call system and perform routine checks throughout the day to ensure the residents' care and well-being.

On February 04, 2026, between 10:00 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff # (S1-S5). Five (5) out of five (5) cannot corroborate this claim of (R1’s) falls were due neglect or lack of care.

(Evaluation Report continues LIC 9099--C)