complaint·August 24, 2023

Residents interviewed did not have firsthand knowledge of incident that occurred. Resident verified window screens had been recently placed on windows in residents rooms and along with locks on the windows; there were no screens or locks on North or South hallway windows according to resident. Residents that were outside of the facility and noticed C1 on the ground, but did not witness how C1 got there. Staff interviewed were not witnesses to the incident that occurred. It was revealed that C1 did not get the "special" attention needed as the facility was in the process of hiring additional staff. Staff stated that C1 was "acting" normal and nothing deemed unusual. Staff stated that C1 tried to leave facility on April 14, 2022 the night C1 arrived but was re-directed. Staff stated on April 16, 2022 med tech notified emergency response team 9-1-1. Outside source records reviewed dated 04/16/2022: Trauma Notes: BIBH S/P fall from a second story building approximately 20-25 feet. Per by standers patient lander headfirst onto pavement. Per flight crew patient was intubated at approximately 1900 hours. Patient had schizophrenia since age 21, but was functional on medications until a few months ago, when they deteriorated and admitted to mental health facility, then discharged to assisted living with family absence, and patient jumped from second floor due to all their SCZ symptoms and delusions recurring. Based on the evidence, interviews conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. An exit interview was conducted with Gabriela Zamora, Manager. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Manager and her signature on this report confirms receipt of the Licensee Rights.