Complaint Investigation Report

Allegation #1: Resident sustained an unexplained fall while in care.

The complaint alleged that the client (C1) was admitted to hospital on 01/07/2024 for a fall. On June 5, 2026, the department interviewed the Administrator (A1), who denied the allegations. A1 stated that C1 got out of bed to use the bathroom without calling for staff assistance and did not use a walker. Suddenly, the staff heard a noise and discovered C1 on the bathroom floor. A1 reported that the staff immediately called Emergency Services (ES), who transported C1 to Riverside University Health System (RUHS), where C1 was admitted with a fractured left tibia on 01/07/2024 and discharged on 01/10/2024.

On the same day, the department interviewed two staff members, C1 and C2, both of whom confirmed they had received fall-prevention training. The department also interviewed two clients, identified as C1 and C2, who reported that staff members assisted them when needed. Client C1 reported that they previously disliked using a walker or asking for assistance. However, they now call for help when necessary and have begun using a wheelchair instead of a walker.

Additionally, the department attempted to interview four other clients (C3 to C6), but unfortunately, they were unable to answer any questions due to their health conditions.