complaint·April 23, 2025

Regarding the Allegation : Staff is not providing adequate care and supervision of a resident while in care. This complaint alleged that staff did not supervise R1 who had 3 witnessed falls. Toured the facility with S1, LPA Calderon did not notice any negative interactions between staff and residents. Records review indicate the following: Physician report indicate health issues and is ambulatory, Preplacement plan indicates that R1 has unsteady gait. Incident reports indicate R1 had 3 witnessed falls on 04/13/2025, 04/14/2025 and 04/18/2025. Incident report indicates that all falls happened in the night shift. Hospital records indicate minor injuries and R1 was returned to the facility. Interviews indicate the following: 4 out of 4 staff deny the allegation. R1 could not answer any questions due to health issues. 13 out of 14 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff is not providing adequate care and supervision of a resident while in care” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Peggy Clark (S1).