Complaint Investigation Report

The investigation revealed the following:

Allegation: Facility staff neglect resulted in resident being dropped

The allegation alleges that a resident was dropped by staff and did not experience a fall as reported.

During the facility inspection, LPA observed staff assisting a resident with getting out of a chair and transferring to a wheelchair. LPA observed staff had their hands appropriately placed to provide support.

During record review, LPA received and reviewed an Unusual Incident/Injury Report that states on 03/01/2026 at 5:57am, R1 stated they were reaching for their remote and fell out of bed on their back side. The resident was assessed and checked no injuries to report. Residents Power of Attorney was notified, and the resident spoke with them. Additionally, LPA received and reviewed the Notes for Resident R1 from 04/09/2025 through 03/11/2026 that indicates on 03/01/2026 at 5:57am R1 “was reaching for (their) remote and in (their) own works, (they) fell on (their) Keister, and there was no bumps bruising, no injury POA was notified.” A later Note on 03/01/2026 at 1:45pm indicates “resident was complaining of pain to (their) left side, Resident was transported to St Mary’s Hospital.” LPA received and reviewed Resident R1’s Admission Package the includes a Fall Risk Notice that states “Regency Palms Long Beach can’t always prevent falls and other personal injuries but we will do our best to work with the Residet to identify ways to stay safe.” LPA received and reviewed seven (7) staff training logs on Relias and observed staff have received training regarding Transferring and Proper Positioning.

During interviews with Staff S1-S8, were asked if there were any incidents regarding a resident being dropped while providing assistance , eight (8) out of eight (8) stated no, there have been no incidents regarding staff dropping a resident.

During interviews with Residents R1-R9, were asked if they have been dropped due to staff neglect during transferring or assistance, nine (9) out of nine (9) stated no, they have not been dropped by staff. Additionally, during an interview Resident R1 stated they were not dropped by staff, and they fell while reaching for their television remote.

Allegation: Facility Staff are not keeping accurate records.

The allegation alleges that facility staff are not accurately documenting incidents and changes of conditions.

During record review, LPA received and reviewed an Unusual Incident/Injury Report that document a fall for R1 on 03/01/2026 at 5:57am, R1 stated they were reaching for their remote and fell out of bed on their back side. The resident was assessed and checked no injuries to report. Residents Power of Attorney was notified, and the resident spoke with them. Additionally, LPA received and reviewed the Notes for Resident