LPA Bunker interviewed Staff #1–#4 (S1–S4). All four staff members (4 out of 4) stated that staff assist residents who are non-ambulatory and require support. S1–S4 reported that the resident does not require assistance transferring from the wheelchair to the bed, and stated that staff are always available to assist if needed. Staff stated that the resident is not a fall risk, and there is nothing in the resident’s medical records indicating a history of falls. 4 out of 4 staff members denied that the resident ever fell thirty-five times and stated that the resident had no injuries or bruises related to falls. 4 out of 4 staff members reported that the facility conducts rounds every two hours, or more frequently when safety risks are higher, and that no staff witnessed or heard the resident fall. S1-S4 also stated that the resident was not lying on the floor. 4 out of 4 staff members stated that the staff are always available to help. All four staff (4 out of 4) denied the allegation.

LPA Bunker interviewed Residents #1–#6 (R1–R6). All six residents (6 out of 6) stated that staff assist residents who are non-ambulatory and need help. 6 out of 6 residents reported they had not witnessed any residents falling and stated that residents do not fall at the facility. All residents confirmed that staff are always available to assist and that their daily care needs are being met. 6 out of 6 residents stated they are happy living at the facility and have no concerns. R1–R6 denied the allegation.

W1 stated that the resident, who ambulates via wheelchair, reported needing assistance transferring from the wheelchair to the bed. W1 reported that the resident claimed to have fallen thirty-five times but had not sustained any injuries or bruises from the alleged falls. W1 also stated that the resident could not provide dates or times when these falls occurred, and there were no witnesses to verify the incidents. W1 stated that the resident claimed they had been lying on the floor because staff allegedly refused to help. W1 stated that the resident reported there were no witnesses who ever saw the resident on the floor.

The Department reviewed the resident’s Physician’s Report (dated 10/01/2024), Appraisal/Needs and Services Plan (dated 07/15/2025), Functional Capability Assessment (dated 07/15/2025), and Pre-placement Appraisal Information (dated 07/15/2025). There was no indication that the resident had a history of falls, was considered a fall risk, or required assistance transferring from the wheelchair to the bed. Documentation reflects that the resident uses a wheelchair and is able to get in and out unassisted.

4 out of 4 staff members stated that they conduct rounds and room checks during the night. During one of these checks, a staff member observed a resident lying on the floor. The resident had created a pallet using a pillow, blanket, quilts, covers, and bed linens. When staff asked the resident why they were on the floor, the resident stated, “I like sleeping on the floor; it’s comfortable.” S1–S4 reported that staff assisted the resident back into bed; however, the resident repeated that they like sleeping on the floor for comfort. S1-S4 also stated that the resident was not lying on the floor, and staff never refused to assist the resident. All four staff members (4 out of 4) denied the allegation.

LPA Bunker interviewed Residents #1–#6 (R1–R6). All six residents (6 out of 6) stated that the staff provides residents with comfortable accommodations. 6 out of 6 residents stated they did not witness a resident lying on the floor. 6 out of 6 residents confirmed that staff are always available to assist, their daily care needs are being met, and staff provide the necessary care and supervision. R1–R6 stated they are happy living at the facility and have no concerns. All six residents (6 out of 6) denied the allegation.

W1 stated that the resident claimed they had been lying on the floor because staff allegedly refused to help. W1 also reported that the resident reported there were no witnesses who ever saw the resident on the floor.

The Department and Administrator toured the facility to observe and identify any signs of neglect, abuse, or other immediate health and safety concerns. No signs of neglect or abuse were observed during today's visit. The facility was found to be clean, safe, sanitary, and in good repair.

Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegations. 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 deemed unsubstantiated. There were no deficiencies cited. LPA Bunker provided Administrator Mary Jane Montiano with copies of the Complaint Investigation Reports LIC-9099 and LIC-9099Cs. An exit interview was conducted.