Complaint Investigation Report

Per the Reporting Party (RP) Resident #4 (R4) also sustained multiple falls while at the facility and that staff did not call emergency transport to take the resident to the ER after sustaining a fall. The complaint was referred to the Community Care Licensing Investigations Branch (IB).

During an initial complaint visit on 05/29/2025 between 10:30AM and 04:45PM, LPAs Valeria Conway, Martha Arroyo and Kelly Dulek and Licensing Program Manager (LPM), Kristin Heffernan, briefly toured the facility with former Executive Director (ED), Monica Reyes. LPA Arroyo conducted a medication audit. LPAs and LPM interviewed the former ED, conducted a file review and obtained copies of pertinent documents relevant to the investigation.

IB Investigator conducted both telephonic and in-person interviews with staff, residents, and other relevant parties on the following dates: 06/12/2025, 06/17/2025, and 08/07/2025. Additionally, IB Investigator also obtained and reviewed copies of medical records for all four (4) residents from St. John’s Hospital.

Resident #1 (R1) was admitted to the facility on 10/18/2017. R1’s primary diagnosis included Parkinson’s disease, bipolar disorder, anxiety disorder, and dementia. R1 requires full assistance with ADLs, including personal hygiene, medication administration, and mobility. R1 is non-ambulatory and relies on a wheelchair, requiring two-person assistance for transfers and toileting, as well as 15-minute checks due to being a high fall-risk status. Despite these needs, R1 sustained multiple falls at the facility. On 04/06/2025, R1 fell from her wheelchair and sustained an intertrochanteric femur fracture. On 05/04/2025, R1 was found on the floor with no injuries. On 05/11/2025, R1 fell again while attempting to rise from bed, resulting in a comminuted left hip fracture requiring surgical intervention. These incidents occurred during a period of significant staffing shortages, during which increased supervision required by R1’s care plan was not consistently provided.

Resident #2 (R2) was admitted to the facility on 03/24/2025. R2’s primary diagnoses include dementia (moderate Alzheimer’s), diabetes, a prior left femur fracture, and left wrist/radius fractures. R2 is confused and disoriented at baseline and requires maximum assistance for grooming and dressing, is dependent for bathing and toileting, and is unable to manage R2s medications. Although ambulatory, R2 has poor balance and is at very high risk for falls.