Complaint Investigation Report

Allegation #1: Facility staff left resident on the ground for an extended period of time .

The complaint alleged the facility left R1 on the ground for several hours after a fall on 11/15/2025 and 11/17/2025, and that no immediate assistance was provided.

On September 25, 2025, between 9:00 AM and 11:30 AM, the Licensee (LPA) conducted interviews regarding an allegation. The Licensee denied the allegation, stating that the residents did not fall but rather sat on the floor and refused to get up.

During the same time frame, LPA interviewed the Administrator (A1), who also denied the allegation. A1 explained that the staff is trained to assist residents in the event of a fall and to call 911 if there are visible injuries or if a resident complains of pain.

Additionally, LPA spoke with the previous Administrator (A2), who similarly denied the allegation. A2 mentioned that Resident 1 (R1) prefers sitting on the floor and often refuses assistance when the staff attempts to help R1 get up. A2 emphasized that the facility respects the rights of the residents. LPA also interviewed three staff members during this time. Each staff member denied the allegation, stating that their protocol is to first check if a resident is okay and not in pain if a fall occurs.