complaint·March 25, 2026

R1 suffered an unwitnessed fall on December 24, 2025 at 4:30am per the incident report dated December 26, 2025. Staff #1 (S1) discovered R1 on the floor calling for help while on their way to use the bathroom. Based on the admission agreement signed by R1 on April 3, 2024, page 2 of the admission agreement states that the facility does not provide a 24-hour awake staff, however staff would be on site in case of an emergency. Upon S1's initial assessment, there were no visible injuries, so S1 safely transferred R1 back to bed. The same day at 7:59am, S1 reported the fall to Staff #2 (S2) via text message. S1 subsequently reported the fall to hospice the same day approximately 9am per the incident report where S1 was advised to administer Tylenol for pain. On December 25th approximately 11am, R1 began complaining of left foot pain per the incident report. Hospice staff arrived to assess R1 and placed an order for a mobile X-ray. On December 26th, the X-ray technician arrived approximately 3:45pm to obtain X-rays. The X-ray results dated December 26th at 3:13pm indicated displaced partially impacted inter/subtrochanteric fracture with varus deformity, femoral diaphysis intact, right hip fracture. Hospice contacted R1's representative, and a decision was made to send R1 to the emergency room for further evaluation and treatment. Based on the interviews, one of three staff confirmed R1 expressed pain the day of the fall evidenced by groaning, however the two remaining staff denied R1 was in pain the day of the fall. It was not until December 26th when S1 observed R1's leg swelling when hospice staff alerted S1 prior to R1's shower approximately 8-9am. The investigation revealed that facility staff failed to immediately notify hospice after the fall which was discovered approximately 4:30am. S1 reported to S2, their direct supervisor, approximately 3.5 hours later after the fall, and an hour later to hospice. Although there were no visible injuries per the statement of three of three staff; it was not until two days later, December 26th, where visible changes to the leg was observed where R1's leg became swollen approximately 8:30am per S1. At this point, it was the responsibility of the facility to seek emergency medical attention prior to the X-ray technician arriving. Per the Department's Provider Information Notice (PIN) 25-06-ASC released on June 24, 2025, the PIN outlines protocols in Residential Care for the Elderly (RCFEs) when emergency services may be necessary and to help ensure residents receive timely medical care. The PIN indicates that the licensee shall immediately place a 9-1-1 call if a resident is experiencing any "imminent threat" and any symptoms which includes "falls with complaints of pain or loss of range of motion" or "obvious broken bones" which caused R1's leg to swell that facility failed to do. Therefore, based on interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff did not seek medical attention for resident in care in a timely manner is deemed SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D. An exit interview was conducted with Administrator Irvin Mendoza, and a copy of this report including the appeal rights and Confidential Names (LIC 811) were provided at exit.