Complaint Investigation Report

LPA Marrufo obtained The Activity Report for R1's Apartment. The Activity Report for R1's Apartment indicates that on 08/03/2025 at 10:21 PM, R1's pendant has an "Assistance Required" activity. The response time is indicated to be 40 minutes and 35 seconds. The "Performed by" column is blank.

LPA Marrufo obtained copies of Corrective Action reports for staff S1 and S2. Both Corrective Action reports state, "...on 8/3/25 you failed to respond to two resident's pendant in a timely manner. This directly impacts our residents quality of care and safety that Brookdale is expected to provide."

During interview on 08/21/2025, resident R1 stated that he/she rolled out of his/her bed and could not pick himself/herself up from the floor. R1 stated to have pressed his/her emergency pendant about 20 minutes after falling to the ground. R1 stated to have been able to reach for the phone in his/her bedroom and called 911 about 30 minutes after pressing his/her emergency pendant. R1 stated the facility staff arrived in R1's bedroom after the paramedics had already arrived.

During visit on 08/21/2025, ADM stated that S1 and S2 reported to ADM that they had not received R1's emergency signal on their pagers. ADM stated to have checked their pagers and saw that R1's emergency signal was found in their pager histories.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information.

This report was reviewed with ADM Zeinab Donner and a copy of this report and appeal rights were provided.