complaint·October 28, 2025

Allegation: Staff did not provide proper supervision to resident in care resulting in a broken hip. The allegation alleges a resident fell at the facility resulting in a broken hip and staff did not know how the resident fell. During the facility inspection, LPA observed all walkways and hallways were observed clean, clear, and free of hazards and obstructions. All hallways had ample lighting. During record review, LPA received and reviewed R1’s Physician’s Report, dated 01/01/2025, that indicates R1 is ambulatory and is able to independently transfer to and from bed. It is indicated R1 uses a walker for unsteady gait and requires assistance with bathing, grooming, and dressing. LPA received and reviewed R1’s Appraisal/Needs and Service Plan, dated 04/09/24, that indicates R1 requires assistance with activities of daily living (ADL), and that R1 refuses assistance and says they are able to do it themselves. LPA received and reviewed the Point of Care Audit Report that documents the time resident health and safety checks are conducted, bathing assistance is provided, and meal attendance. In the document, LPA observed health and safety checks conducted on 02/12/2025 at 11pm and 11:26pm, and on 02/13/2025 at 2:43am and 7am. Additionally, LPA observed meal attendance documented on 02/13/2025 at 8:11am. During interviews with Staff S1-S6, they were asked if R1 was a fall risk, five (5) out of six (6) stated no, R1 was not a fall risk. Additionally, Staff S1-S6 were asked how often residents who are fall risks are checked on, six (6) out of six (6) stated as frequently as possible, every 15 to 30 minutes. During interviews with Residents R2-R10, were asked if they feel there is enough staff to provide proper supervision, nine (9) out of nine (9) stated yes, there is enough staff to provide proper supervision. Additionally, Residents R2-R9 were asked if staff check on them when they are in their room, nine (9) out of nine (9) stated yes, staff conduct frequent checks on them when they are in their rooms. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator, Susana Fuentes, and a copy of this report was provided.