Complaint Investigation Report

Allegation: Staff did not address a resident's change in medical condition

The details of this complaint alleges that the facility failed to re-assess (R#1) after multiple falls.

On October 30, 2025, the department conducted a review of medical records and found the following:

On January 19,2025, (R#1) was transported to Long Beach Medical Center after slipping out of their wheelchair while attempting to use the restroom. The hospital performed imaging tests that revealed no fractures. (R#1) was discharged the same day.

On February 4, 2025, (R#1) sustained a facial contusion from an unwitnessed fall in the facility and was admitted to Los Angeles Community Hospital for treatment and discharged February 7,2025.

On April 5, 2025, (R#1) sustained a hematoma due to hitting their head when transferring from their wheelchair to their bed. (R#1) received treatment at Long Beach Memorial Hospital and was discharged the same day.

On May 31, 2025, (R#1) experienced a mechanical fall in their bathroom and complained of shoulder pain. (R#1) was transported to Los Angeles Community Hospital. During this visit, imaging tests revealed that (R#1) sustained a closed, displaced fracture of the right clavicle. (R#1) was discharged the same day with documentation indicating orthopedic surgery would be scheduled. On June 5, 2025, (R#1) returned to the hospital due to injury-related pain.

On June 17, 2025, the department conducted an interview with (R#1), who stated they have vertigo and a fall risk. (R#1) confirmed they have experienced falls in the facility and injuries as a result of the falls.

On September 2, 2025, the department conducted an interview with the assistant administrator (A#1), who stated (R#1)’s Needs and Services Plan and care plan were not updated after (R#1)’s falls.