Complaint Investigation Report

Allegation: "Facility is not sufficiently staffed to meet the needs of residents in care:"

The complaint alleges that there are not enough staff working in the facility to meet resident needs. Staff schedules were reviewed for the past month. Review of staff schedules revealed that there are five (5) care staff plus two (2) charge nurses on shift during the 06:00AM - 02:30PM shift. There are four (4) care staff plus two (2) charge nurses scheduled during the 02:00PM to 10:30PM shift. On the overnight shift, there are two (2) care staff and one (1) charge nurse scheduled. In addition, there are activity staff present daily, as well as management staff to assist during the day and evening hours. Interviews with staff revealed the current schedule is sufficient to meet the needs of residents in care. 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.

Allegations: "Resident sustained multiple falls due to staff neglect" and " Facility staff did not adequately address resident's fall risk resulting in injuries:"

Interviews revealed that during the overnight shift that ended on 06/12/2026, R1 had awoken during the night. R1 attempted to get out of their bed and had slid to the floor four (4) times. R1 does have a bed alarm, so each time staff responded to R1's room to assist them. Interviews revealed that all residents are regularly observed every two (2) hours during the overnight shift. In the early morning hours of 06/12/2026, staff responded to R1's room every hour when R1 was getting out of bed. Additionally, R1 does have a landing mat next to their bed and R1's family provided R1 a lower bed to mitigate a potential fall risk. Interviews and documents reviewed revealed R1 has not fallen from a standing position while residing at the facility, but typically slides down to the floor when they attempt to get out of bed. Although R1 did hit their head on the wall at approximately 04:20AM on 06/12/2026, staff was present in R1's room at that time and was a result of a behavior, not a fall. Responding emergency personnel indicated "[patient] was assessed, no injuries found." R1 has not sustained any injuries observed when getting out of bed unassisted. Staff indicated that when R1 ambulates about the facility using their walker, staff do walk with R1 to ensure their safety. The information obtained during the investigation did not include evidence sufficient to corroborate the