Complaint·March 19, 2026

Observations revealed the following: The memory care unit has a spread layout and houses approximately 35 residents, including residents requiring incontinence care and identified as fall risks. Staff reported grouping residents in a common area for visibility. At the time of the visit, approximately 4–5 staff were present. Based on the layout and resident care needs, this level of staffing may limit the ability to provide continuous supervision, particularly during overnight hours. Interviews conducted revealed the following: Staff (S1–S5) reported the fall was unwitnessed and discovered during morning rounds, and staff were unable to determine when or where the fall occurred. Staff (S1) reported four staff were scheduled; however, only three staff were present on the night shift due to staffing changes. Staff (S2–S3) confirmed three staff were assigned to the nocturnal shift. Staff (S6) reported that three staff typically care for approximately 35 memory care residents during night shift and stated this may not be sufficient to meet resident care needs. Witnesses (W1–W5) reported concerns regarding night supervision, staffing levels, and prior unwitnessed falls. Witnesses (W6–W7) reported no concerns. Records review revealed the following: Review of the February 2026 staffing schedule confirmed that three staff, including registry staff, were assigned to the overnight shift on 02/13/2026–02/14/2026. Records confirmed the resident sustained an injury consistent with a fall that occurred overnight. Documentation did not identify the time or circumstances of the fall and did not demonstrate staff awareness at the time of the incident. Nursing notes indicate limited information was available from the overnight shift regarding the incident. Review of incident reports and resident records identified a pattern of unwitnessed falls in February 2026, including incidents on or about 02/06/2026, 02/10/2026, and 02/14/2026, where residents were found on the floor with injuries during morning hours. Documentation consistently indicated staff were unaware of when or how the falls occurred. While appropriate medical care was provided after discovery, records do not demonstrate effective overnight monitoring. Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is issued on the attached (LIC-9099D). An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator.