Complaint Investigation Report

The investigation revealed the following:

Allegation: Due to staff neglect, resident fell and sustained a fractured nose and black eye

The department received and reviewed the Unusual Incident Report dated 12/2/25, stating R1 was being transported to her room when S6 reported she tripped, and R1 fell forward out of her wheelchair and hit her face. Upon review of medical records from Harbor – UCLA Medical Center dated 11/29/25, R1 was admitted due to a mechanical fall. On 7/9/26, the department reviewed Admission Record and noted R1 was admitted to the Gardena Retirement Center on 9/20/24 and has a history of falls. Diagnosis per Physician’s Report dated 7/29/25, HTN (hypertension), HLD (hyperlipidemia), hypothyroidism, and dementia. Per review of Resident Appraisal dated, 12/2/25, R1 was hospitalized (11/29/25 – 12/1/25) for an accidental injury – resulting in a nasal bone fracture. CT scan shows nasal bone fracture, negative head CT for acute bleed. Overall health condition included dementia, non-ambulatory, motor impairment: uses a wheelchair, special diet: Low carb, puree, need assistance with bathing and dressing. Per review of Appraisal/Needs and Services, 12/15/25, R1 has no known allergies, poor posture and poor appetite. Per interview with S1, 7/9/26, R1 did not fall in the shower, she fell while being transported to her room following being showered. S1 stated it was an accident. On 7/9/26, R1 stated she was scared as S6 was going to fast. Per interview with S5, 7/9/26, R1 leans to the side. Staff repositions R1 in the straight position, but R1 slides back down and continue to lean to the side. Per interview with S6, 12/4/25, R1 does not like to use the chair. S6 stated she almost lost her balance as she pushed R1 in the wheelchair after R1 abruptly put her feet on the floor which caused R1 to fall forward.

LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 3 out of 5 denied the allegation and 2 staff did not know. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation and 1 resident confirmed it.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Due to staff neglect, resident fell and sustained a fractured nose and black eye,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator, Susie Fuentes.