Complaint Investigation Report

Interviews with staff member (S1) and House Manager, Stephanie Harmon-Christensen, indicated that Licensee would work NOC shift and sleep through their shift. House Manager stated that staff member (S3) would also sleep through their shift. Physician’s Report (LIC 602A) for resident (R3) states R3 needs “total dependent assistance” for all activities of daily living (ADLs). Resident Appraisal for R3 on file states that R3 needs special observation/night supervision (due to confusion, forgetfulness, wandering) as they are “unable to get out of bed/supervision.” Appraisal/Needs and Services Plan for R3 dated December 18, 2025 states R3 “needs assistance with all activities and all ADL’S.”

S1 stated that R3 has cut their arm from falling out of bed. S1 stated that R3 has fallen out of bed twice during Licensee's shift. S1 stated that S3 has left R3 on the floor because they couldn't get R3 up on their own. S1 stated that S3 gave R3 a blanket and pillow while they laid on the floor. S1 stated that the floors are hard. S1 stated that they did not know when R3 fell. S1 stated that resident (R2) has fallen and resident (R4) has fallen out of bed (LPA verified Incident Reports submitted regarding falls for both residents). S1 stated that all falls have been during Licensee's shift. S1 stated that R2's most recent fall was at approximately 7:15 AM ending in Licensee's shift. S1 stated that they lifted R2 into bed and called the paramedics. S1 stated that R2 bumped their head. S1 stated that House Manager told S1 to call paramedics.

The Department received information from R3’s Home Health (HH) regarding R3’s fall. HH reported that R3 is mostly bedbound and is unable to turn or transfer self. HH reported to have visited R3 on January 3, 2026. HH reported that staff member (S2) stated that R3 had an unwitnessed fall and night shift caregiver (S3) left R3 on the floor for possibly one (1) to two (2) hours. HH reported that S2 had stated that S3 did not call supervisor until the end of their shift. HH reported that supervisor found R3 soaked in urine and blood to their right arm while face down on the floor next to their bed. HH reported that supervisor contacted paramedics and R3 was returned to bed and provided basic wound care. HH reported assessing R3’s arm and found no signs of infection. HH reported providing R3 wound care and instructing care staff regarding wound care as ordered by physician. HH reported providing extensive fall prevention education to care staff. HH recommended bed alarms and 24 hour closer supervision.