complaint·October 31, 2025

On June 08, 2025, R1 was found by MedTech 1 (MT1) lying on their bedroom floor at approximately 9:30 AM after staff reported not seeing R1 at breakfast. Per facility policy, staff are to check on residents when they do not show up for meals. Emergency services were contacted and R1 was transported to UCI Medical Center where he was treated for pressure injuries, abrasions and signs of prolonged immobility. Per records obtained, EMS report confirms a call at 9:23 AM, with arrival at 9:30 AM. The EMS report noted pressure ulcer to left check, abrasions to chest and knee and stable vital signs. Per UCI Medical Records R1 was admitted on June 8, 2025, for trauma and sepsis secondary to gangrenous cholecystitis. The medical notes document that R1 was found down after approximately 24 hours in which large pressure ulcer was found on the left cheek; an abrasion to chest and right knee; strong smell of urine; clothes soiled; and soft tissue trauma consistent with prolonged immobility. UCI medical documents and EMS report corroborate that injuries resulted from prolonged immobility. Per interview with Health & Wellness Director (HWD) Suzette Paige, R1 was independent and typically attended all meals. She received a call from MT1 that R1 was found on the floor because they had missed breakfast. HWD Paige stated that the night shift failed to perform required checks despite policy requiring one per shift. From records obtain, Brookdale Senior Living has a Night Check Policy – CS-100-16 Effective April 1997 where resident care staff should make night checks of the residents. Interviews with MedTech and Caregiver confirmed that there was no overnight welfare checks completed on June 7th & 8th. Facility did not follow or practice the policy of verifying the independent residents’ well-being during night shifts which contributed to the prolonged delay in discovery of R1 in their apartment. Per interviews, two staff interviewed mentioned there was a facility informal rule, to wait for two consecutive missed meals before checking on residents. This informal rule practiced by facility staff demonstrates neglect with delayed responses and violation of the facility procedures. The facility failed to provide adequate supervision and neglected to ensure the health and safety of residents in care. Based on interviews conducted and records reviewed, Resident sustained multiple pressure injuries due to neglect. The following is cited by the California Code of Regulations, Title 22, Division 6. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) (Complaint Investigation Report continued on LIC9099-C) An exit interview was conducted and a copy of this report, LIC809-D, appeal rights and confidential names list was provided to Executive Director and Health & Wellness Director.