Complaint·June 16, 2026

LPA conducted interviews with five (5) staff members, all of whom stated that any hospital beds can be adjusted quickly when providing care to the residents. Staff members then adjust the bed height back to normal when they are done with the residents. Staff members interviewed denied experiencing or witnessing any residents’ fall because of bed height. LPA conducted an interview with S2 who denied lowering R2’s or any residents’ beds to avoid being questioned by paramedics. LPA conducted interviews with 14 residents, none of whom expressed any concerns regarding height of their beds. LPA’s attempted interviews with seven (7) additional residents were unsuccessful due to their cognitive condition. LPA’s attempted interview with R2 was unsuccessful because R2 was no longer a resident of the facility and lacked available contact information. LPA's attempted records review regarding R2's fall was unsuccessful due to lack of available records. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.