Complaint Investigation Report

Interviews revealed that facility staff would attempt to keep residents who were identified as fall risks in the common areas under staff observation during the day and would conduct safety checks every 30 minutes to 1 hour if residents who were fall risks were in their rooms alone. Interviews revealed that R1 would often attempt to get up from a wheelchair or the bed without staff assistance and would fall. Interviews revealed that R1 had a roommate who would open the door to their shared room and R1 would enter the room and would often fall. Interviews and records review revealed that R1 had a fall in January 2023. Interviews revealed that staff heard R1 calling for help and found R1 on the floor and R1 stated that they had been on the floor for about 30 minutes before staff assessed R1. Interviews revealed that R1 complained about pain and the nurse was called to assess R1 and R1 was not observed to have any injuries. The staff contacted 911 who came to assess R1 for any injuries and R1 refused to go to the hospital. Interviews revealed that R1 was kept in the common areas during the rest of the day.

The Department has investigated the above-mentioned allegation and based on interviews and record review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Executive Director Stefanie Ancheta , to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.