complaint·January 9, 2026

Regarding allegation: Staff does not provide adequate supervision resulting in resident falling It is alleged that Staff does not provide adequate supervision resulting in resident falling. It is alleged that R1 has experienced falls while living at the facility due to lack of care and supervision. On 8/30/2025, R1 fell forward from edge of bed. Resident evaluation was performed, and resident was able to move all extremities without pain. On 8/31/2025, R1’s doctor’s nurse practitioner examined R1 on a video call and determined that there was no need for hospital visit. On 9/22/2025, R1 experienced another fall while transferring from recliner with staff assistance. R1 was transported to hospital. Investigation consisted of interviews with staff, residents, and review of R1 facility file. LPA was unable to interview R1 since R1 was in hospital during initial visit, and on today’s visit, R1 is no longer residing at facility. During interview with the residents, three (3) out of fifteen (15) residents experienced a fall at the facility. R7 stated that R7 did not need assistance after fall, R15 did not recall details of fall, and R14 stated that R14 lost balance. Twelve (12) out of fifteen (15) residents stated that residents don’t need supervision or were not able to respond whether residents needed supervision. R1, R7, R9, and R14 stated that staff take good care and supervise residents. During record’s review, R1’s physician’s report and R1’s appraisal reports, it revealed that R1 is non-ambulatory and has no history of fall. During interview with staff, eight (8) out of eight (8) staff denied the above allegations. S1 stated that the facility has twelve (12) caregivers, two (2) med-techs, and two (2) supervisors in the morning and afternoon shifts. The facility has a policy of a wellness check every 2 hours. S4 and S5 stated that there is enough staff to provide supervision for residents. Staff stated that facility protocol is to always evaluate residents after sustaining a fall and transport residents to hospital for evaluation if necessary. Based upon the investigation, client and staff interviews, document review, and LPA observations, the facility provides adequate supervision to residents in care. Report continues on page LIC-9099c... Regarding allegation : Staff did not seek medical attention to resident. It is alleged that facility staff did not seek medical attention in a timely manner for R1. On 8/30/2025 and 9/22/2025, R1 suffered falls where it is alleged that no medical attention was provided. Investigation consisted of interviews with staff, residents, and review of R1 facility file including incident reports, doctor’s communication, and nurse notes for R1’s incidents. The investigation reveals the following: The facility staff sought medical assistance for R1’s falls. On R1’s fall on 8/30/2025, facility staff performed R1’s evaluation after the fall and facility staff determined that R1 was able to move all extremities without pain or discomfort. On 8/31/2025, the facility sought medical support to R1’s doctor office and nurse practitioner determined to apply antibiotic cream to red nose. The nurse practitioner determined that no other medical assistance was needed. R1’s responsible party was notified, and responsible party refused emergency room transport. On 9/22/2025, R1 experienced another fall while transferring from recliner with staff assistance. R1 sustained a bump on left side of head. R1 was transported to hospital for further evaluation. During interviews with the residents, nine (9) out of fifteen (15) residents stated that staff is supportive of residents’ medical needs including setting up appointments, going to doctor, or hospital. Residents stated that residents were confident that staff would assist with their medical needs if requested. Interview with staff revealed that eight (8) out of eight (8) staff denied knowledge of the above allegation. Staff stated that staff follow protocol for resident’s falls to seek medical attention after a resident fall. Staff denied ever refusing to seek medical attention for any resident in care. Staff stated that, per protocol, staff follows contact information with residents’ physicians and residents’ responsible party. Based upon the investigation, client and staff interviews, document review, and LPA observations, the facility staff provided first aid and sought medical attention to R1's physician after both fall incidents. R1’s physician and responsible party were notified after each fall. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview held with Executive Director Virginia Garcia. A copy of the report was provided.