Complaint·April 22, 2026

Interviews conducted revealed the following: Staff (S1) reported the incident was unwitnessed and discovered at approximately 6:00 AM during morning rounds. Staff (S2–S3) reported the resident was found with a bump on the head at approximately 5:30 AM. Staff (S1–S3) reported they were unable to determine when or where the fall occurred. Staff (S1) reported four staff were scheduled for the overnight shift; however, three staff were present due to staffing changes. Staff (S2–S3) confirmed three staff were assigned to the overnight shift. Staff (S6) reported that three staff provide care for approximately 35 memory care residents during the overnight shift. Witnesses (W1–W5) reported concerns regarding night supervision, staffing levels, and prior unwitnessed falls. Witnesses (W6–W7) reported no concerns. Of the residents interviewed, (2) out of (5) residents reported staff do not check on them during the night or do not recall staff presence. (3) out of (5) residents were unable to confirm whether staff conducted nighttime checks. (4) out of (5) residents reported prior falls or being on the floor, including (1) resident who reported a fall that was not reported to staff. (6) out of (6) residents were not able to provide interviews due to their medical conditions. Observations revealed the following: LPA toured the memory care unit and observed multiple hallways and resident rooms extending in different directions, not visible from a single central area. The unit houses approximately 35 residents, including residents requiring incontinence care. Staff reported grouping residents in a common area for visibility. At the time of the visit, approximately 4–5 staff were observed present with residents. 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. Incident reports and progress notes confirmed that (R1) sustained an injury consistent with a fall that occurred overnight. Documentation did not identify the time or circumstances of the fall. Progress notes dated 02/14/2026 document that caregivers reported the injury in the morning and indicated limited information was available from the overnight shift regarding the incident. Review of incident reports and progress notes dated 02/06/2026, 02/10/2026, and 02/14/2026 document residents were found on the floor with injuries during morning hours, with no documentation identifying when or how the falls occurred. Resident records indicate that all 35 out of 35 memory care residents require incontinence care and supervision due to behaviors such as wandering/exit seeking behaviors. Based on the evidence gathered, including interviews, 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, Section 87411(a), which requires sufficient staff to meet resident care and supervision needs. A citation is issued on the attached LIC 9099-D. An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator.