Complaint Investigation Report

Regarding the allegation: Staff did not adequately supervise resident while in care. It was alleged that Resident #1 (R1) was not adequately supervised as R1 was locked out of R1’s room and found on the floor sleeping with a possible fall or head injury. Interviews conducted with the Wellness Director, Gloria Morales revealed that R1 is in the memory care unit, which is a separate and locked unit within the building. Interviews with staff and Gloria revealed that R1 wanders the hallways throughout the memory care unit and occasionally dances. Gloria stated that on 03/12/2025 staff notified Gloria that R1 was verbalizing feeling dizzy. Gloria instructed staff to notify the family of R1 to take R1 to urgent care for examination. R1 was sent to urgent care and the hospital on 03/12/2025 and returned the same day with the diagnosis of a urinary tract infection (UTI) and dehydration. Interviews conducted with nine (9) staff denied R1 of falling. Interview with R1’s family member revealed that they do not believe that R1 had a fall or head injury on 03/12/2025. Additionally, R1’s family member stated that staff are constantly communicating in regard to R1’s condition. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.