Complaint Investigation Report

were no fall preventative measures in place during the nighttime. S3 was live-in staff and could not provide any information about the care R1 required during the daytime or nighttime. S3 denied checking on residents during the nighttime.

On 1/23/2026, at approximately 1500 hours, staff called 911 for R1 because they were complaining of left hip pain. R1 was admitted to Sutter Roseville Medical Center and diagnosed with a left hip fracture. The hospital contacted facility staff to determine how R1 may have sustained the fractured hip and there were no records of any recent falls. However, there was a text message from S3 to the facility group chat that indicated S3 found R1 on the floor on 1/23/2026 at 0400 hours. S3 placed R1 back in their bed. It was unknown how long R1 was on their bedroom floor prior to S3 finding them. Staff interviews indicated that protocol for unwitnessed falls is to call 911.

Based on interviews conducted and documentation obtained, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 9099-D page. As a result of the resident's serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 is being assessed for a violation that the Department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted.

Exit interview conducted. A copy of the report and appeal rights provided.