Complaint Investigation Report

On 03/04/2026 at 2:19pm, the Department interviewed W1. W1 stated R1 sustained may falls and the facility did not notify W1 about the first fall and learned about it from the hospital instead.

On 04/29/2026 at 4:32pm, the Department interviewed W2. W2 stated R1 is ambulatory and is a fall risk that needed a better line of sight to prevent falls.

The records review showed that R1 was admitted to the facility in May 2024 with documentation indicating that R1 was ambulatory and able to complete personal care tasks independently. The physician’s report (dated 04/18/2024), and the admission orders (dated 05/04/2024), reflected that R1 did not require assistance with bathing, dressing, grooming, toileting, or mobility at the time of admission. The pre-placement appraisal (dated 05/11/2024), noted mild mobility impairment, moderate forgetfulness, confusion, and occasional need for night supervision due to wandering. These early records established R1’s baseline functioning and cognitive limitations.

In March, April, and August 2025, R1 was involved in resident-to-resident altercations resulting in minor injuries. On 07/22/2025, staff documented that R1 experienced dizziness in the morning. On 10/30/ 2025, R1 sustained an unwitnessed fall resulting in a hematoma above the right eye and was transported to the hospital. On 11/08/2025, R1 sustained another unwitnessed fall, reporting that R1 fell from the bed and hit the back of the head, resulting in another hematoma and hospital transport. Hospital records from 11/08/2025 - 11/12/2025, documented intracranial bleeding and a left cerebral convexity acute subdural hemorrhage. These incidents demonstrated a pattern of unwitnessed falls and repeated head injuries.

In December 2025, records showed a series of health-related entries and additional falls. R1 returned from Alamitos Belmont Rehabilitation, a skilled nursing facility on 12/03/2025. On 12/04/2025 R1 complained of stomach pain, and on 12/11/2025, R1 complained of right leg pain. On December 14, 2025, R1 sustained an unwitnessed fall at 0515 hours and was assisted back to bed. On 12/15/2025, R1 sustained another unwitnessed fall and was found on the bathroom floor complaining of head pain. Hospital records from St. Mary Medical Center (dated 12/15/2025 - 12/16/2025) documented a large mixed-density subdural hematoma with midline shift. On 12/16/2025, ICU staff notified the facility that the incident would be reported due to R1’s history of repeated hospitalizations for unwitnessed falls. R1 remained hospitalized through 12/22/2025, 2025, with records noting frequent falls and a decision to forego neurosurgical intervention. A final December entry dated 12/27/2025, indicated no complaints.