Complaint Investigation Report

Allegation #1: Staff did not adequately address resident's fall risk.

Allegation #2: Resident sustained injuries due to staff neglect.

The complaint alleges that the staff did not adequately address Resident #1 (R1’s) fall risk. It is reported that (R1) had unwitnessed fall in November 2025 and which resulted in right eye injury leading to blindness. After the incident (R1) received short-term nursing care post discharge from Ronald Reagan UCLA Medical Center and returned to the facility fearing that (R1) may fall again. No further details regarding these matters were provided.

Resident #1 (R1) was admitted to Welbrook Santa Monica on June 30, 2023, in accordance with the facility’s Admission Agreement (dated 06/30/23). (R1) voluntarily terminated their residency on February 21, 2026, at which time personal belongings were removed from the premises. From November 19 to November 23, 2025, (R1) received medical attention at Ronald Reagan UCLA Medical Center for a visual injury, necessitating transportation to the hospital for appropriate treatment.

On February 5, 2026, and May 7, 2026, between 11:34 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Six (6) out of the six (6) staff members could not validate both claims. The initial assessments conducted by (S1-S2) indicated that (R1) did not have a prior history of falls from (R1’s) primary care physician. The Physician’s Report LIC 602A (dated 06/14/23) did not identify (R1) as a fall risk. However, the facility’s Senior Living Functional Assessment (ISP) (dated 05/07/26) noted that (R1) had experienced a few falls and that a fall prevention plan was implemented. It was confirmed by (S1-S2) that, despite initial assessment noting a history of falls, (R1) did not experience any falls during care at the facility. (S1-S6) confirmed that before (R1) being admitted to Welbrook Senior Living, (R1) had a medical assessment that revealed visual impairment related to glaucoma.

On November 19, 2025, an incident involving (R1) was reported as having an unwitnessed fall. At 4:50 AM, a staff member discovered (R1) sitting on the bed, holding (R1’s) eye. Upon examination, a skin tear or cut near (R1’s) eye was identified. The area was promptly cleaned, and emergency services were called; (R1) and were subsequently transported to the hospital. (S1) confirmed that a thorough inspection of (R1’s) room revealed no blood on the floor or any evidence of a fall. It appears likely that (R1) unintentionally rolled over in bed and hit (R1’s) face against the sharp corner of the night stand, resulting in the eye injury.