Complaint Investigation Report

The allegation is that resident sustained fracture due to staff lack of supervision.

On 4/4/2025 and 5/12/2025, LPA interviewed Executive Director (ED) Marife Durewel. ED stated on 2/23/2025, after dinner, around 5:45PM, resident R1 was found on the floor in his/her room. ED stated R1 stated he/she fell when tried to get his/her back bag. 911 was called by staff and R1 was sent to hospital. ED stated on 2/24/2025, around 2:20AM R1 returned to the facility. ED stated the facility contacted R1's responsible party to have 1:1 24x7 caregiver for R1 after R1 returned to the facility. ED stated the facility has a caregiver sits on a chair by the door of R1's room to monitor R1 and lets R1's door remain open after R1 returned back to the facility.

ED stated on 2/27/2025, at 6:30AM, R1 was found in the bed in his/her room. ED stated on 2/27/2025, around 6:45AM, R1 was found on the floor in his/her room. 911 was called immediately and R1 was sent to hospital. On 3/5/2025, R1 returned to the facility. ED stated R1 has 1:1 24 x 7 caregiver staring from 3/5/2025.

On 4/4/2025, LPA interviewed Health and Wellness Director (HWD). HWD stated the facility contacted resident R1's responsible party to suggest R1 to have a 1:1 24 X 7 caregiver after 2/23/2025. HWD stated R1's responsible party confirmed R1 to have 1:1 24 X 7 caregiver starting 3/5/2025.

LPA interviewed staff S1. S1 stated after 2/23/2025, the door of R1's bedroom is remained open, and there is a caregiver sits on the chair by the door of R1's room to monitor R1 when R1 is in the room.

LPA interviewed staff S2. S2 stated on 2/27/2025, around 6:30AM a NOC shift caregiver told him/her that he/she just checked R1 and R1 was in the bed.

LPA interviewed R1's 1:1 private caregiver (PC1). PC1 stated he/she works from 8:00AM - 8:00PM every day and another 1:1 private caregiver works from 8:00PM - 8:00AM every day. LPA observed a caregiver sat on the chair by the door of R1's room.