Complaint Investigation Report

Allegation #1: Resident had multiple falls in care.

The complaint details alleges that Resident #1 (R1) experienced multiple falls while under care. Reports show that (R1), who resides in the memory care unit, has fallen four times in the past two months and has sustained injuries on (R1)'s body. No additional information has been provided regarding this situation.

Resident #1 (R1) was admitted to Regency Palms Senior Living on February 22, 2025, as indicated by their Resident Lease Agreement (dated 02/20/25) and Identification and Emergency Information (dated 02/21/25). On March 31, 2025, (R1) experienced a fall while receiving home health care from St. Victoria Home Health. The incident was reported by med-tech staff at 6:00 PM. Subsequently, on April 27, 2025, at 6:40 AM, (R1) encountered another fall that caused head injury.

On May 2, 2025, between 09:30 AM and 11:30 AM, the Department interviewed a staff member identified as Staff #1, (S1) the executive director. (S1) confirmed that multiple unwitnessed falls have occurred with (R1) in the past couple of months. (S1) verified the fall dates of March 31, 2025, and April 27, 2025. (S1) claimed that the family representative for (R1) was notified of each incident and received immediate medical attention at St. Mary’s Hospital. It was further stated that (R1) was reassessed with a Resident Assessment on April 29, 2025; however, a fall management plan designed to minimize the risk of falls was not included.

On May 2, 2025, between 11:02 AM and 11:10 AM, the Department interviewed a witness identified as Witness #1 (W1), the family representative for (R1). (W1) reported that staff informed (W1) about (R1)’s recent fall on April 27, 2025, which resulted in several injuries. (W1) also mentioned another fall a few weeks earlier, although (W1) could not provide the exact date and time. That previous fall caused bruises around both eyes and (W1) was notified of it. Both incidents required medical attention at St. Mary’s Hospital.

On May 2, 2025, between 11:35 AM and 11:45 AM, the Department interviewed a resident identified as Resident #1 (R1). (R1) shared a recent experience of a fall in (R1)'s room that resulted in a head injury, mainly because it occurred in a familiar area of the room. (R1) claimed to have prior falls, but the specifics could not be recalled in detail.