Complaint Investigation Report

R1 did not have any fall incidents while residing at this facility. R1 did not require any assistance with mobility. R1 was once sent out to a hospital in March 2026 per R1’s physician’s order for health condition unrelated to fall incident. LPA conducted interviews with eight (8) residents, all of whom stated they do not require assistance or supervision when they go out in the front yard or back yard. LPA conducted interviews with Staff #1 (S1) and #2 (S2), both of whom stated that R1 liked to walk around the facility. R1 sometimes picked up palm tree seeds from the ground. Staff members tried to redirect R1 whenever R1 had the seeds. Neither S1 nor S2 remembered R1 wearing blood stained shirt. LPA conducted interviews with additional four (4) staff members, all of whom stated they redirected R1 from picking up anything from the ground. All staff members interviewed stated that none of the residents required one-on-one care. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated.

It was alleged that staff does not ensure resident is being adequately fed. Information received indicated that Resident #1 (R1) lost weight due to inadequate amount of food served. LPA conducted interviews with eight (8) residents, none of whom expressed any concerns about the amount of food served. LPA conducted interviews with six (6) staff members, all of whom stated all residents have been served with more than enough food. Two (2) out of six (6) staff members interviewed stated that R1 may have lost some weight due to constant wandering around the facility which has large buildings and outdoor areas. LPA’s attempted interview with R1 was unsuccessful due to lack of available information. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated.

It was alleged that staff are not safeguarding residents’ personal belongings. Information received indicated that Resident #1 (R1) lost a hat and was observed wearing someone else’s shoes. LPA conducted interviews with Staff #1 (S1) and Staff #2 (S2), both of whom stated that R1 once did not have shoes. R1 told staff that they threw the shoes over the facility fences. Staff could not recover R1’s shoes. R1 came to the facility with only one pair of shoes, so staff provided a donated pair of shoes that were good fit for R1. R1’s hat was found within the facility and returned to R1 by a staff member. LPA conducted interviews with four (4) additional staff members, all of whom stated that residents sometimes lose their belongings due to their cognitive condition, but staff members always try to find rightful owners when anything is found in the facility. Continued on LIC9099-C....