Unexplained Injuries While in Care

The details of the complaint alleged that (R#1) sustained unexplained injuries while in care.

On 5/12/26, during the records review, the Department obtained evidence that showed (R#1) sustained injuries to the knees and shoulder while in the care of staff. Interviews and email correspondence indicated that (R#1) was being assisted in the bathroom by (S#1) when the fall occurred, and that family-reviewed video footage showed (S#1) entering (R#1)’s room alone despite a documented two-person assist requirement. In addition, the evidence showed that (S#1) did not disclose the fall for approximately 36 hours and provided an account inconsistent with the injuries observed (“fell on their bottom”). Moreover, the evidence demonstrates that facility leadership acknowledged that (S#1) was placed on leave pending investigation and subsequently terminated. In addition, the Department reviewed a copy of the Special Incident Report dated 1/22/2026; the Department noted that the report documented that (R#1) “slid down to the ground” while being assisted in the restroom, that (R#1) later complained of pain to both knees and the left arm, and that staff requested medical evaluation due to ongoing pain.

On May 14, 2026, during an interview with former facility administrator (A#1), he stated that he was informed by the Registered Nurse one day after the incident that (R#1) had leaned against the wall and slowly slid to the floor while being assisted in the bathroom. He reported that (R#1)’s service plan identified them as requiring a two-person assist for toileting, and that facility Registered Nurse and Reminiscence Coordinator were dispatched for immediate assessment and follow-up. In addition, (A#1) further stated that surveillance footage later provided by (R#1)’s representative showed only (S#1) entering the room and assisting (R#1) to the bathroom where the incident occurred. He reported that, following review of the incident, all Reminiscence staff were re-in serviced by the Reminiscence Care Coordinator regarding the requirement to follow resident care plans, specifically related to two-person assist interventions.

Evaluation Report continues LIC 9099-C

The details of the complaint alleged that staff failed to properly report an incident involving (R#1).

On 5/12/26, during the records review, the Department obtained evidence reflecting that the fall occurring on January 19 was not reported by the assigned caregiver, and the family learned of the incident only after observing injuries the following morning. Further evidence showed that the staff failed to notify management or the family and that the incident remained undisclosed for more than 24 hours. Facility leadership did not dispute the failure to report and indicated that the matter was under internal review. In addition, the Department reviewed a copy of the Special Incident Report dated 1/22/2026; the Department noted that the report acknowledged a delay in reporting and properly documenting the incident involving (R#1), including the statement: “There was a delay in reporting incident and documenting properly.”

On May 14, 2026, during an interview with former facility administrator (A#1), he stated that (S#1) was disciplined for failure to follow the resident’s care plan and for the delay in reporting the incident, and that (S#1)’s employment was ultimately terminated.

Resident Was Left Soiled

The details of the complaint alleged that (R#1) was left soiled while in care.

On 5/12/26, during the review of the records, the Department obtained evidence indicating that paramedics returned (R#1) to her room late at night and that the staff member who received her placed her in bed without checking her condition. The following morning, the morning lead discovered (R#1) soaked in urine, with a strong ammonia odor present in the room, and contacted the family. The facility acknowledged communication gaps among staff regarding (R#1)’s return and did not dispute the family’s account.

Evaluation Report continues LIC 9099-C

Staff Did Not Meet Resident’s Incontinence Needs

The details of the complaint alleged that staff did not meet (R#1)’s incontinence needs.

On 5/12/26, during the records review, the Department obtained evidence indicating that (R#1) experienced repeated episodes of dry briefs despite known incontinence, and staff did not identify or report signs of urinary retention or constipation. (R#1) was later hospitalized with severe fecal impaction causing urinary obstruction, requiring inpatient treatment. It was reported that toileting and hydration protocols previously discussed with the facility were not implemented. The facility did not dispute the account and acknowledged ongoing concerns regarding care coordination. In addition, the Department reviewed a copy of the Special Incident Report dated 1/22/2026; the Department noted that the UCLA Emergency Room report documented constipation.

On May 14, 2026, during an interview with former facility administrator (A#1), he stated that resident care plans are reviewed during weekly care meetings and are also discussed during daily shift crossovers to ensure staff remain aware of individualized care needs. (A#1) explained that care plans are accessible to staff through their individual electronic tablets for both review and documentation purposes.

Evaluation Report continues LIC 9099-C

The details of the complaint alleged that staff failed to prevent another resident from entering (R#1)’s bedroom.

On 5/12/26, during the records review, the Department obtained information that showed staff did not prevent another resident from entering (R#1)’s bedroom. Email documentation shows that a male resident entered (R#1)’s room late at night wearing only undergarments and got into bed with her. Staff reportedly had difficulty removing the resident without waking (R#1). The family reported that the room was normally locked due to known wandering behavior but was not secured on the night of the incident. Facility leadership acknowledged the event and agreed to provide an overnight caregiver at the facility’s expense as a temporary safety measure.

On May 14, 2026, during an interview with former facility administrator (A#1), he stated that that Sunrise’s expectation regarding resident room access is consistent throughout both daytime and nighttime hours, and that resident rooms in the Reminiscence unit are to always remain unlocked. He reported that he was informed by (R#1)’s representative the morning after the incident that another resident had entered (R#1)’s room and laid down next to her in bed. He stated that (R#1)’s representative advised she had reviewed surveillance footage related to the incident and shared the footage with him.

During this investigation, LPA found sufficient evidence to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).

An exit interview was conducted, and a copy of the Complaint Report was given to Sean Tahizadeh/Executive Director.