complaint·April 3, 2025

On April 3, 2025, during subsequent visit, LPA Lee obtained a copy of elopement procedure training and sign in sheet. The training was conducted March 17-28, 2025. During the investigation, LPA conducted 5 additional staff interviews (S8-S12) via telephone and/or obtained written statements due to their shift schedule and availability at the time of LPA’s visit. The investigation revealed the following: Resident sustained a serious injury while in care The detail of the complaint alleges that on February 2, 2024 R1 sustained a fractured hip while eloping from facility. On 1/17/2025 between 8:30am and 9:40am, LPA interviewed Administrator David Cole (A1) who did not deny the allegation and informed LPA that he was aware of the incident and completed an Unusual Incident Report (UIR) when it occurred. A1 stated that all exit doors are delayed egress and equipped with a secondary alarm. Despite the alarms on the exit door, R1 was able to get out of the facility and subsequently found in the rear of building. On 01/17/2025, LPA reviewed ambulance transport document, which revealed that on 2/2/24 at 10:00pm R1 was seen by a passerby laying on ground in alleyway near facility. 911 was called, R1 reportedly complained of hip pain. Emergency services transported R1 to Ronald Reagan Medical Center. The review of R1's Emergency Department to Hospital admission/discharge documentation (MR #6530489) dated 2/2/24 revealed that R1 arrived via ambulance transport to ER and was subsequently admitted to hospital. R1’s diagnosis was Intertrochanteric Fracture, Osteoporotic Hip Fracture. R1 was treated and discharged on 2/10/2024. Page 2 of 4 Based on the information gathered, there is sufficient evidence to support the stated allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Resident left facility unsupervised The detail of the complaint alleges that on February 2, 2024 Welbrook Senior Living staff was not aware that R1 had left the facility until they were notified by the paramedics who responded to the call of a woman lying in an alleyway behind the facility. On 1/17/2025 between 8:30am and 9:40am, LPA interviewed Administrator David Cole (A1) who confirmed the allegation. On 0/17/2025, LPA interviewed 7 staff regarding the allegation and of those interviewed, 7 out of 7 stated that R1 did not elope on their shift but they were aware of the incident. 7 out of 7 stated that they are all training on the alarm system and the elopement protocol. Of the 5 additional staff interviewed, 4 out of 5 were on shift during R1’s elopement; 4 out of 5 stated they did not hear the alarm as they were downstairs preparing for a shift transition. On 4/3/25 during subsequent visit, A1 confirmed that the alarm can not be heard on first floor of the facility. Additionally, 4 out of 5 indicated that they are trained on the alarm system and the elopement protocol. On 1/17/25 LPA obtained/reviewed Unusual Incident Report (UIR) dated 2/3/24 explaining the incident which corroborated the allegation. Page 3 of 4 Based on the information gathered, there is sufficient evidence to support the stated allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 article 12 are being cited on the attached LIC 9099D. Exit interview conducted and copy of report given to David Cole, Executive Director. Page 4 of 4 Staff failed to report resident injury to responsible party On 1/17/2025, LPA obtained/reviewed the Unusual Incident Report(UIR) dated 2/3/24 sent by facility. The report indicated that the responsible party was contacted. On 1/17/2025 staff #6 indicated that she contacted responsible party to inform him of the incident. Based on the information gathered, there is insufficient evidence to support the stated allegation Although the allegations above 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 are UNSUBSTANTIATED No deficiencies were cited for the above allegations. Exit interview was conducted. A copy of this report was provided to David Cole, Executive Director.