Complaint·August 27, 2025

Page 2 of 4 Based on interview with reporting party (RP). RP stated that R1 fell in the bathroom on 08/05/24 at approximately 0400 hrs. and screamed for help for 3 hours until someone (a facility staff) found R1 at 0730 hrs. and called 911. Based on the investigation, R1 sustained an unwitnessed fall and was found by facility staff at approximately 0700 hours. R1 was admitted to the hospital by ambulance at approximately 0740 hours. On 08/06/24, R1 was discharged back to the facility with a diagnosis of an acute brain bleed and was placed on hospice care on 08/05/24. The facility is equipped with a fall monitoring system set up in each resident’s room in the facility, however, there were no notes indicating the monitoring system caught R1’s fall on 08/05/24. Based on interviews with 2 witnesses (W1 and W2), W1 reported that he/she received a phone call from the facility staff at approximately 0730 hours on 08/05/24. Staff reported to W1 that R1 fell and was sent to the hospital. W2 stated, upon notification of R1s fall, they watched a video recording of R1’s room. The video recording was from a personal camera installed in R1s room by W1 and W2 and facility granted permission for the camera. The purpose was to remotely monitor and keep an eye on R1. The camera captured movement and sound made by R1 but there was no visual captured from the bathroom. Page 3 of 4 W2 stated the following series of events.The camera detected the motion caused by R1 and recorded R1 getting out of bed at approximately 0400 to 0430 hours and entering the bathroom. W2 heard when R1 fell in the bathroom. R1 fell at approximately 0400 hours, afterwards can be heard screaming for help for two to three and a half hours before a staff came and assisted R1 at 0730 hours. There was no visual capturing R1s fall in the bathroom but could be heard in the background screaming for help. Based on interviews with 4 staff (S1 to S4). S1 stated that on 08/05/24, his/her shift started at approximately 0600 hours and was present. When S1 was asked how three hours could have passed between the time that R1 fell and when R1 was found by facility staff, S1 stated that it was because “someone was not caring for R1.” S2 stated, on 08/05/24 a caregiver (name unknown) reported to S2 that R1 fell and was not assisted for three to four hours. S2 stated one caregiver and one med tech at night are scheduled to assist all residents. S2 stated that it was possible that R1 had fallen and waited three to four hours because a care giver may not check on residents often enough. S3 stated, on 08/05/24, his/her shift started at approximately 0630 hrs. S3 was alerted by care staff that R1 had fallen. S3 entered R1s bathroom but does not know how long R1 was on the floor waiting for staff assistance because no one told him/her. S3 stated safety checks are supposed to be conducted every one to two hours at night, however, checks are not documented. Page 4 of 4 S4 stated R1 was under hospice care. (note: Hospice Care for R1 was initiated after the incident of 08/05/24). S4 stated facility will call hospice to assess R1 before calling 911. S4 stated the facility is equipped with a system called Safely You, which monitors residents’ rooms and alerts facility staff when a fall is detected. S4 was asked how R1 fell on 08/05/24, S4 stated he/she has no recollection of the incident. When asked the length of time R1 had to wait for staff assistance, S4 stated that it was possible that R1 fell and left unattended for three hours because there could have been an emergency involving another resident that would have caused facility staff to not check on R1 for three hours. Based on review of R1s medical record and facility observation notes, R1 is a fall risk and has sustained multiple unwitnessed falls and R1 requires increased supervision and assistance, R1 is diagnosed with dementia and has a high fall risk. R1 has 30 documented witnessed and unwitnessed falls between 05/25/24 and 09/24/24. A majority of the falls were “witnessed” by the facility’s monitoring system, however on 08/05/24, R1 sustained an unwitnessed fall and no time stamp to indicate R1s fall. R1s care plan includes daily checks from 10:30 a.m. to 9:00 p.m. 4x, from 11:00 p.m. to 4:00 a.m. 3x and from 7:00 a.m. to 8:30 p.m. 4x. No documentation if wellness check were conducted. Based on observations, interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Citations are issued based on the California Code of Regulations (CCR) Title 22, Division 6, Chapter 8 for Additional Personal Rights of Residents in Privately Operated Facilities and Incidental Medical and Dental Care are cited on the attached LIC 9099D. An exit interview was conducted with Jessica Pryor Regional Operations Specialist, a copy of the report and appeals rights were provided