Complaint·May 7, 2026

During today's visit the investigation revealed the following: in regard to the allegation, “Staff neglect resulted in resident sustaining a fracture.” It is alleged that on 12/01/2025, R1 fell out of bed and sustained a broken right hip. This allegation was investigated by the Investigation Bureau (IB) and was assigned to Investigator Salant. LPA reviewed IB interviews which revealed the following: There is not enough evidence to suggest that the staff members were neglectful or demonstrated lack of care and supervision resulting in R1 falling out of bed. At the time R1 fell out of R1’s bed, there were no specific doctors' orders on file recommending that R1 have a bed with rails or any type of specialized supervision. R1 was known and allowed to ambulate on and off R1’s bed on R1’s own, prior to R1’s fall without assistance. There is not enough sufficient evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was held and a copy of this report was provided to the Administrator, Claudia Sanchez.