Complaint Investigation Report

The investigation revealed the following:

Allegation: Facility staff are not properly supervising residents who are a fall risk

The detail of the complaint alleges R1 have had multiple falls which may have been due to lack of proper supervision.

On May 12, 2026, at 12:15am the department interviewed Executive Director (A1), who was not with the facility during time of the complaint, however he was able to provide the department with documentation from that time frame. On issue of staff supervision, A1 added that they have adequate coverage to meet the residents need and if someone “calls out,” there is a plan in place to have the shift covered.

On May 12, 2026, between 12:40pm and 1:20pm the department interviewed 5 staff (S1-S5) regarding the allegation. Of those interviewed, 5 out of 5 denied the allegation stating that staff always provide proper supervision to the residents. 5 out of 5 stated that they have had training on fall prevention and it is refreshed frequently during in-service training/meetings. Additionally, 5 out of 5 staff state that there are enough staff to meet the residents’ needs. Lastly, the staff stated that they “work together as a team to get the job done.”

On May 12, 2026, the department interviewed 4 residents (R2-R5). Of those interviewed, 4 out of 4 stated that they are treated well and staff would help them if they needed. 2 out of 4 stated that they had a fall at the facility and staff were there to help them. Lastly, 3 out of 4 stated that they feel that there is enough staff to meet their needs. 1 out of 4 stated that there is not enough staff.