complaint·January 29, 2026

The investigation revealed the following: regarding the allegation “Staff neglect resulted in resident sustaining an injury due to a fall.” It is alleged that staff neglect resulted in a resident sustaining an injury due to a fall. Five (5) out of five (5) staff interviewed denied this allegation. Staff interviews revealed that R1 was considered a high fall risk and staff took interventions to prevent R1’s falls. Staff interviews revealed that R1 was placed on 30-to-45-minute room checks, a fall mat was placed in their room, a wheelchair was used to assist R1, and staff attempted to keep R1 in common areas so that R1 was always in line of sight of staff. Records reviewed revealed that R1 was admitted into the facility on 11/27/2024. On 12/03/2024, R1 was moved into the facility memory care due to a change in condition. Review of Unusual Incident Reports revealed the following: on 06/01/2025, R1 had a witnessed fall and was observed with discoloration to their eye and nose and R1’s responsible party was notified and took to urgent care the same day. On 11/30/2025, R1 had a witnessed fall. R1 was assessed by staff and did not see any visible injuries. Staff contacted R1’s responsible party and R1’s physician regarding the fall. On 12/25/2025, R1 was observed laying on the hallway floor with discoloration to their forehead. Staff called 911 and R1 was sent to a local hospital for further evaluation. R1 was released later that day with no new orders but staff documented R1 was placed on frequent checks as a result of this fall. On 01/15/2026, staff conducted a room check on R1 and discovered R1 on the floor with a minor cut to their forehead. Staff called 911 and R1 was taken to a local hospital for evaluation. R1’s responsible party and physician were notified of R1’s fall. R1 was admitted to the hospital and released back to the facility on 01/16/2026 with hospice care services. Review of R1’s change of condition assessment conducted on 10/26/2025, revealed that R1 was assessed as a high fall risk. LPA Ramirez attempted to interview R1’s responsible party but all attempts were unsuccessful. LPA Ramirez attempted to interview R1 but all attempts were unsuccessful. LPA Ramirez attempted to interview R2-R5 but due to cognitive impairment, responses were unreliable. Record review of R1’s observation notes documented room checks conducted by staff, R1’s falls and notification to R1’s responsible party and physician about the falls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . SEE 9099-C for continued narrative Staff did not ensure resident was adequately hydrated.” It is alleged staff did not ensure R1 was adequately hydrated. Five (5) out of five (5) staff interviewed denied this allegation. Staff interviews revealed that R1 was always provided with water, however, R1 would at times refuse to eat or drink water. Staff interviews revealed that staff would encourage R1 to eat or drink water when R1 would initially refuse but R1 would get agitated if staff persisted. Review of staff observations notes revealed that staff documented R1’s refusal to eat or drink and staff notified R1’s responsible party and physician. LPA Ramirez did observe staffing notes that indicated R1 ate and drank water without resistance. LPA Ramirez attempted to interview R1’s responsible party but all attempts were unsuccessful. LPA Ramirez attempted to interview R1, but all attempts were unsuccessful. LPA Ramirez attempted to interview R2-R5 but due to cognitive impairment, responses were unreliable. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies were cited. Exit interview was conducted. A copy of this report was provided.