Complaint Investigation Report

During interview on 05/15/2025, resident R1 stated that R1’s last fall occurred in R1’s bedroom. R1 stated that during the fall, the staff were in the bedrooms of other residents or in the common area. R1 stated the staff provide R1 with enough supervision. R1 stated staff are always with R1 and walk R1 to the eating area and restroom, including while R1 showers.

During visit on 07/22/2025, LPA Marrufo interviewed staff S1-S4. During interviews, S1 and S3 stated that R1 experienced a fall in April 2025. S1 and S3 stated that R1 was sitting in the living room while S1 and S3 were in the bedroom of a resident who required cleaning and changing assistance of two staff. S1 and S3 stated R1 had an alarm attached to R1’s walker and S1 and S3 regularly reminded R1 to use the alarm if R1 needs assistance with standing or ambulating. S3 stated R1’s walker has a sign reminding R1 to use the alarm for assistance. S1 and S3 stated R1 stood up without using the alarm and S1 witnessed R1 fall. S1 was able to immediately assist R1 after the fall.

During visit on 07/22/2025, LPA Marrufo observed a sign on a food tray in the living room near a chair. The food tray had a sign taped to it that said, “Call for Help! Before getting up.” LPA Marrufo observed R1’s walker. LPA Marrufo observed that R1’s walker also has a sign attached to it that says, “Call for Help! Before getting up.” LPA Marrufo observed R1’s bedroom has a sign that says “Call don’t fall” and has a photograph of an alarm button.

During interview on 05/15/2025, R1 stated to have an alarm installed on R1’s bedroom floor. R1 stated to also have an emergency pendant, which LPA Marrufo observed during interview. R1 stated staff respond to the pendant alarm within two minutes, including when R1 pushes the pendant alarm at night.

During interviews on 07/22/2025, S1-S4 stated that they respond within a minute to R1’s emergency pendant alarm.