Complaint Investigation Report

The investigation revealed the following:

Allegation: Facility staff neglect is resulting in residents suffering from multiple falls

On 5/21/25, LPA Shirley reviewed special incident reports from January 2025 to April 2025. During review of the incident reports LPA Shirley observed 8 incident reports that were resident falls. File review revealed that one resident, R5, is considered a fall risk. R5 fell on 2/1/25 and 4/30/25. LPA observed that there was an assessment completed on 3/30/25, and interview with the Wellness Director stating that there was a care plan in place.

LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff neglect result in residents suffering from multiple falls. Of those interviewed, 9 out of 9 staff answered no. LPA interviewed Resident-1 thru Resident-10 (R-1 thru R-10). LPA asked, does staff neglect result in residents suffering from multiple falls. Of those interviewed, 5 out of 10 answered yes, and 5 answered no.

Allegation: Facility staff not seeking medical assistance for residents in a timely manner

On 5/21/25, LPA Shirley reviewed special incident reports from January 2025 to April 2025. During review of the incident reports LPA Shirley observed that residents were assisted timely by staff members upon request by residents, per incident occurrences or by observation. LPA Shirley reviewed the Acute Care Transfer log received on 5/8/25 and 5/21/25 regarding staff assisting residents by transferring the residents from this facility and the reasons for the transfers.