Complaint Investigation Report

During the investigation 5 of 7 witness interviews confirmed the complaint allegation as it was reported.

On August 27, 2025, Resident 1 (R1) was sent to the hospital and diagnosed with an acute head injury and scalp laceration as a result from a fall sustained at Beach Terrace Memory Care on August 27, 2025. The resident arrived around 6:40 pm at Los Alamitos Medical Center and was discharged back to Beach Terrace Memory Care a few hours later around 9:10 pm. When discharged from Los Alamitos Medical Center R1 was given orders to follow up with their primary care provider within 5 to 7 days to discuss and further evaluate the injury, and for staple/suture removal and wound check.

However, document review reveals that R1 suffered at least two additional falls prior to the scheduled September 8, 2025, follow up visit to have the staples removed from their head. Incidents evidenced include a fall on August 28, 2025, the day after being released from the hospital after being treated for the initial fall on August 27, 2025, that resulted in a head injury that required three staples. Document review revealed that R1 was pushed to the ground by another resident and landed on their back around 7:00 am on August 27, 2025.

On September 2, 2025, R1 suffered a fall and was sent to the hospital after being discovered on the ground around 2:40 pm in their bathroom and bleeding from the ear. R1 was sent to West Anaheim Medical Center and diagnosed with a fall, closed head injury, and UTI. R1 was treated and released the following day: September 3, 2025, with orders to follow up with their PCP in one week.

The document was consistent with what was discovered during witness interviews. R1 suffered three falls within six days, sustained head injuries and it was discovered R1’s toenails were severely overgrown.

None of the seven individuals interviewed disputed or challenged any incidents as they were reported. Further, document review revealed information and details that were consistent with witness interviews.

Regarding the allegation: A lack of care resulted in complaints of pain and discomfort due to severely overgrown toenails

During the investigation 7 of 7 witness interviews confirmed the complaint allegation as reported. While R1 was in the hospital on August 27, due to a fall and sustaining a head injury it was reported by a family member that R1 complained of pain to their feet while at Los Alamitos Medical Center.