Complaint Investigation Report

According to a review of facility records, an incident report dated 10/26/2024 disclosed that R1 fell while using the restroom. R1 was assisted back up and back to R1's room. R1 later expressed pain but staff checked mobility and touched area of pain on R1. R1 did not show reaction or pain. On 10/25/25, R1 woke up complaining of leg pains. The house manager arrived at the facility and observed R1 able to stand with signs of possible soreness. On 10/26/24, R1 was observed to be more lethargic, which then led the manager to tell staff to send R1 to the ER.

Based on facility records, R1 sustained a hip fracture from the fall. R1 underwent a partial hip replacement and was transferred to a rehabilitation facility.

According to an interview with S1, S1 was not present when R1 initially fell. S1 was present on 10/25/2024. S1 stated looking back S1 should have sent R1 out on 10/25/24. At the time, S1 reported that R1 could not verbally communicate the amount of pain. S1 observed R1 to stand up as R1 normally would. S1 stated R1 is a fall risk but it is not indicated because they are frequent due to R1's health condition. S1 stated the facility sent R1 out when they observed a change of condition.

LPA Valerio attempted to interview S2; however, S2 did not return LPA's call. Based on facility records. S2 worked during the time R1 experienced the fall on 10/24/24.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 1) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility.