Complaint Investigation Report

On 07/14/2025, the facility submitted an Unusual Incident/Injury Report (IR) about an incident that occurred on 07/05/2025. The IR states that staff found resident R1 on the living room floor of R1’s apartment. Staff observed R1 to be face down and had a skin tear on his/her left elbow. R1 reported to staff that R1 was in pain and wanted to be sent to the hospital. Staff called 911 and paramedics transferred R1 to the hospital.

R1’s Personal Service Plan is dated 03/12/2025. R1’s Personal Service Plan states the following: “[R1] will require assistance with [his/her] medications…Resident does not require dressing and grooming assistance…Resident does not require showering and bathing assistance…Resident does not require bathroom assistance…Resident is independent going to and from the dining room or community activities”

R1’s Progress Notes from 07/05/2025 at 9:00 PM state, “Resident used pendant and was seen on the floor in [his/her] living room next to [his/her] couch faced down on the floor. Resident is alert and oriented and is able to make needs known. CP [Care Provider] notified writer, when asked resident stated [he/she] doesn’t remember how [he/she] got on the floor…Resident denies [he/she] must have been sleepy, resident had earlier requested and was administered PRN [redacted] for insomnia at 0730 an hour later resident was seen in couch sleeping and was advised by writer to be escorted to bed as to not fall asleep on [his/her] couch, resident verbalized understanding.”

On 07/23/2025, LPA Marrufo conducted an interview with staff S1. During interview, S1 stated that prior to R1’s fall incident, the only care service R1 was receiving was medication management and night checks.

On 02/04/2026, LPA Marrufo conducted a telephone interview with R1’s family member, FM1. During interview, FM1 stated the he/she did not know if R1 required supervision when R1 fell on 07/05/2025. FM1 stated R1 refused to pay for care that R1 thought he/she did not need. FM1 stated he/she was working on getting R1 more care, but R1 became deceased.

This agency has investigated the complaint allegations listed. Based on interviews and review of records, the department has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Assistant Executive Director Yasen Matar and a copy of this report was provided. Page 2 of 2. END REPORT