Complaint·September 26, 2025

S1 and S2 stated R1 was a very complicated resident. S1 stated R1 always said he/she had to leave the facility to go with R1s son and when staff would try and redirect R1, R1 would become upset and hit staff with a cane and say mean things to them in Spanish. S2 stated staff had to rotate constantly when dealing with R1 because they noticed R1 would become a bit calmer when R1 would see a new face and didn’t like dealing with the same staff member the whole day. On 02/06/2024, S1 was working his/her shift as a MedTech and preparing medications to pass out when S1 saw R1 walking toward the front door. S1 told R1 to not go outside, and R1 proceeded to walk out the front door acting like R1 didn’t hear what S1 said. S1 went after R1 but before doing so S1 needed to secure the medication cart and lock it before going outside. S1 said when R1 finally went out the front door, S1 told R1 to come inside, and R1 turned around and began swinging his/her cane toward S1. S1 said as R1 was swinging the cane facing S1, R1 was also walking backwards and suddenly R1 tripped over R1s own feet and fell to the floor landing on his/her left arm. S1 said she did a head-to-toe assessment on R1 and also called for help over the radio. S1 said R1 said he/she had no pain on his/her body or legs. S1 mentioned that S2 arrived and they helped R1 up onto a patio chair and that’s when R1 started complaining of wrist pain and S1 called S4 to come. S1 told me once S4 came, S4 decided to call 911 to get R1’s injuries further checked out and medics arrived and transported R1 to the hospital where R1 was later diagnosed with a fractured left wrist. S3 and S5, stated the complaint received about R1 eloping outside the facility is false. S5 stated the facility has a secure perimeter and staff knew R1’s whereabouts the whole time leading up to his/her fall. S3 added there are no rocks large enough to climb on facility grounds and there were no rocks near where R1 had a fall. Based on photos obtained, the facility has a facility fence preventing residents to go out of the facility without assistance. There were no rock formations that would make the residents climb and cause injury. Based on records review, according to resident appraisal dated 2/1/2024, R1 is able to ambulate with the help of a cane. page 2 of 3 For the allegation of Staff did not provide resident’s records to resident’s authorized representative, RP stated that a family member (F1) has requested information from the facility administrator and believes they are withholding information. In addition, F1 requested to view camera footage but was told that the cameras were not operational and is not being given full disclosure of the incident or full access to R1’s files. According to S3, on the day of R1s accident as well as the times F1 went to the facility, F1 asked how the incident occurred and each time F1 was told how R1 fell, and staff never avoided telling F1 anything. S3 stated no information was withheld from F1 and they had no reason to lie to F1 or not tell him/her what occurred. S3 said F1 asked for video surveillance of the incident, and they told him/her they didn’t have any footage of the fall because their cameras don’t record and are only live cameras. S3 said F1 never came to the facility asking for R1s admission agreement and if F1 did, they would have no problem giving it. S3 said a copy was provided to F1 at the beginning. S1 also added that days after the incident F1 came to the facility to collect R1s belongings and F1 had asked for a copy of R1s contract. S1 said at the time S3 and S4 were not at the facility and advised F1 that S1 couldn’t get a copy at the moment but if F1 came back when the managers were present, they will gladly provide that to F1. S1 said he/she even mentioned emailing or giving S4 a call regarding the contract and maybe S4 would be able to email it over. There were several attempts to contact RP and F1 but never received a response. Based on interviews, records review and observations, the department has determined that 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 allegations are UNSUBSTANTIATED. Report is reviewed and a copy is provided. page 3 of 3