complaint·December 17, 2025

The investigation revealed the following: Allegation: Staff did not ensure that resident's shower equipment was in good repair resulting in a fall. It is being reported that shower equipment was not in good repair, resulting in residents fall. On 12/17/25, LPA Felisa Shirley reviewed the Special Incident Report dated 11/13/25, which reported that R1 slipped out of the shower chair during her scheduled shower, and returned back to the facility on the same day. On 12/17/25, LPA Shirley reviewed the Preplacement Appraisal Information dated 10/22/25, which documents that R1 needs help with bathing. A review of medical report from Gardena Hospital, LP dated 11/12/25 did not indicate a fracture nor a displacement. LPA Shirleys facility tour and inspection on 11/19/25 included an evaluation of the designated shower chair; no deficiencies were identified. During staff interviews, S2 indicated they were able to catch the resident and gently guide R1 into a seated position, preventing a fall. The staff member stated that there were no visible injuries and resident did not hit their head or lose consciousness as a result of the incident. LPA Shirley interviewed staff 1 – staff 8 (S-1 – S-8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 8 (R-1 – R-8). Of those who interviewed 7 out of 8 denied the allegation, and 1 confirmed the allegation. Based on information gathered, LPA Shirley did not find sufficient evidence to support the allegation “Staff did not ensure that resident's shower equipment was in good repair resulting in a fall,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Susie Fuentes.