complaint·February 4, 2026

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff neglect resulting in resident sustaining multiple falls. It is alleged that Resident #1 (R1) sustained multiple falls due to staff negligence. Reports indicate that (R1) experienced several falls over three months: November 2025, December 2025, and January 2026. These incidents were attributed to delays in the emergency call system when responding to (R1's) basic needs, which were not met promptly. Although no injuries were reported, it was noted that (R1's) limited mobility, combined with the lack of assistance, contributed to these falls. No additional details regarding this allegation have been provided. On February 04, 2026, between 11:00 AM and 11:50 AM, the Department interviewed resident members identified as Resident #1 and Resident #2 (R1-R2). Two (2) out of two (2) cannot validate this claim that multiples falls were due to staff neglect in care. (R1) expressed a desire for independence and preferred not to rely solely on care staff. (R1) often took care of basic needs independently. Although (R1) stated that the treatment received from staff was satisfactory, (R1) exhibited impatience and was reluctant to wait for assistance, which sometimes led to falls. Additionally, (R1) reported experiencing gait issues, which caused (R1) to bend low to the ground and end up on the floor. Staff documented these instances as falls, even though (R1) did not perceive them as falls -"I just couldn't get back up." (R2) has frequently observed (R1) being assisted by care staff while in bed. After the care staff leaves, (R1) often becomes defiant and attempts to transfer to an assistive device independently. This behavior frequently results in slips and falls, leading (R1) to use the emergency call system for help instead of asking for assistance beforehand. (R2) stated that (R1) requires staff assistance and will receive it but prefers to work independently. Furthermore, (R2) mentioned that the care staff are responsive when dispatched via the emergency call system and perform routine checks throughout the day to ensure the residents' care and well-being. On February 04, 2026, between 10:00 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff # (S1-S5). Five (5) out of five (5) cannot corroborate this claim of (R1’s) falls were due neglect or lack of care. (Evaluation Report continues LIC 9099--C) (S1-S5) has verified that (R1) requires full assistance due to (R1's) health condition and non-ambulatory status and has had multiple falls. However, they do not agree that multiple falls have occurred with (R1) because of staff neglect. Rather, it is understood that, while care is available, (R1) often prefers to act independently and chooses not to follow the care directives provided. (S1-S3) reported that (R1) experienced several falls; however, in each incident, (R1) did not suffer any serious injuries and refused medical care at the hospital afterward. (S1-S3) reported that medical assessments are performed each time of a fall incident, but no reappraisal is performed. A fall prevention plan has been implemented to enhance (R1's) safety. Key measures have been implemented to ensure (R1's) safety and comfort. The room is kept clutter-free, and frequently used items are stored at waist height to prevent overreaching or bending. Additionally, half bed rails have been installed for extra support, and safety signs have been posted. An Individual Service Plan and a Resident Assessment for (R1) was conducted on January 8, 2026, with contributions from both the medical provider and family representatives which includes prevention of frequent falls. (S4-S5) verified completion of mandated staff training including fall prevention, proper positioning, back injury prevention, hoyer lift usability, and timely response to call lights. On February 04, 2026, between 12:03 PM and 12:20 PM, the Department interviewed witness identified as Witness #1 (W1). (W1), who has a close relationship with (R1), asserts that (W1) is unable to confirm the claim. (W1) stated that while it is true (R1) has experienced multiple falls, it is unclear whether these incidents are the result of staff negligence or a lack of care. (W1) believes that (R1) is receiving adequate care, but (R1) prefers to be independent and can become impatient when waiting for assistance. (W1) is uncertain whether the emergency call system is not being used effectively or if the staff are responding promptly. Additionally, (W1) confirmed that (R1) has an unsteady gait due to health conditions. Consequently, care staff may mistakenly think that (R1) has fallen when, in fact, (R1) may be positioning thyself on the ground for support without having sustained a fall. On February 4, 2026, an inspection was conducted in room #129, which is a shared space. The room was found to comply with all preventive measures, including the installation of half-bed rails, a clutter-free environment, and the positioning of frequently used items at waist height. Additionally, safety signs, a grabber tool, and an operational emergency call system were present. During the inspection, the Department also tested the emergency call systems in rooms #123, #124, #128, #129, and #130, confirming that all systems were in good working order. Care staff demonstrated timely responsiveness, addressing calls within one to two minutes. (Evaluation Report continues LIC 9099--C) A review of Resident #1 (R1’s) service record included Physicians Report LIC 602A (dated 04/02/25), Identification and Emergency Information LIC 601 (dated 04/17/25), Admissions Agreement (dated 04/17/25), Individual Service Plan (dated 04/16/25 & 01/08/26), Resident Assessment (dated 01/08/26) verified that (R1) due to health conditions requires complete assistance and is non-compliant using call light or asking for assistance. Medication Administration Record (dated 01/01/26 - 01/31/26) (R1) is taking (22) prescribed medications and (16) out of (22) causes a significant increase in the risk of falls (ref: National Institute of Health NIH). A further review of Unusual Incident Report LIC 624 (dated 11/08/25, 11/26/25, 12/02/25, 12/05/25, 12/10/25, 12/30/25, 1/22/26 and 01/27/26) verified multiple falls with no serious injuries with medical assessment performed. A further review of the Emergency Call System Log, (dated 01/01/26 - 01/31/26), revealed that only three calls were made from room #129. The response times for these calls ranged from 9 to 11 minutes. Additionally, staff training has been completed through Relias and In-Service sessions covering multiple safety and personal care services. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated . An exit interview was conducted with Esperanza Naaktgeboren, and copies of report was provided.