Complaint Investigation Report

The investigation revealed the following:

Allegation: Resident sustained multiple bruises, due to staff neglect

It is alleged that R1 fell down the stairwell in her wheelchair, resulting in R1 sustaining multiple bruises due to staff neglect. R1 was admitted to this facility on 10/11/23 based on chart’s face sheet. Per review of R1’s chart on 7/2/26, and interview with S1 and S4, R1 was not considered a fall risk. On 7/2/26, LPA Shirley called R1’s prior facility, Primrose Post Acute and noted that R1’s 2023 Fall Risk Assessment considered her a high risk for falls. LPA Shirley reviewed R1’s Physician Report dated 3/11/26, R1 has no auditory impairment, no motor impairment/paralysis and R1 uses a wheelchair and able to self-propel. LPA Shirley observed Physician’s report dated 3/11/26, R1 also has no history of unsafe wandering nor elopement. A review of consultation dated 10/18/24 R1 denies suicidal or homicidal ideation. Per interview with S4 on 4/8/26, R1 is able to access all areas of the facility independently. LPA Felisa Shirley requested and reviewed all incident reports from 7/2025 to current and noted that there was one report of R1 falling. On 4/8/26, LPA Shirley reviewed an incident report dated 3/29/26 reporting R1 being sent to the hospital due to an unwitnessed fall. During interviews on 4/8/26, both R2 and R3 observed R1 in her wheelchair near the stairwell of the main floor rolling back and forth. Residents were located on the main floor of this facility, which includes the Activity room, TV, snacks and the smoking patio. R3 yelled and told R1 to watch out you’re going to fall. Both R2 and R3 observed R1 proceed backwards down the stairs. R2 stated that no one pushed R1 she just rolled back on her on. Per incident report dated 3/29/26, R1 was given medical treatment, taken to the hospital and R1’s primary care physician and family were informed of the incident. LPA Shirley called and spoke to W1 and was told that R1 had no fractures, scans cleared, bruising on the left side of her face, eye, neck and forehead.

LPA interviewed staff 1 – staff 6(S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 6(R1 – R6). Of those who interviewed 3 out of 6 denied the allegation, 1 resident confirmed the allegation and 2 were not sure.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Resident sustained multiple bruises, due to staff neglect,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator, Azucena Reyes.