complaint·April 2, 2025

...Continued from 9099 According to the incident report dated 6/6/23, R1 was found on the ground in front of community entrance with R1’s chair behind R1 at approximately 3:40 p.m. on 6/4/23. 9-1-1 was called and R1 was transported to John Muir Emergency. According to the triage record dated 6/4/23, the chief complaint was a fall. Triage record indicated that R1 fell out of the wheelchair and was down on the ground with wheelchair on top of R1. R1 was diagnosed with traumatic subarachnoid hemorrhage (HCC) and returned to the facility under Suncrest Hospice on 6/8/23. On 7/11/23, the Department interviewed 4 staff (S1, S2, S3 and S4) and 4 residents (R1, R2, R3 and R4), and reviewed the facility’s video camera footage. Video camera footage confirmed that an unknown male held the door opened for R1 to exit and R1 was seen leaving the facility lobby and headed to the left of the facility property. Approximately four (4) minutes later, unknown elderly went into the facility and walks to the front desk, then S3 was seen exiting the facility, and other staff were seen responding outside to the left of the facility. The Department attempted to interview R1, but unable to obtain additional information. On 7/18/23, the Department interviewed 2 staff (S5 and S6). Additionally, interviews with S7 and S8 were conducted on 8/21/23 and 8/23/23 respectively. Although R1’s Physician’s Report dated 5/2/23 indicates R1 is unable to leave the facility, 4 of 8 staff stated residents are able to sit outside in the sun without supervision. Prior to the fall, 3 of 8 staff stated R1 was communicative of R1’s needs to staff. S7 stated that R1 was not a risk of AWOLing. S1 and S8 stated R1 did not require constant supervision and the facility does not monitor front door at all times. S2 stated the facility’s policy is for residents to sign out when they leave the property but not when sitting outside. Based upon the interviews conducted and information obtained during investigation. The above allegations are UNSUBSTANTIATED . A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted and a copy of this report provided.