complaint·December 5, 2025

Record review of R1’s facility files revealed they were admitted on 11/18/23. R1 had a history of falls, and the facility was trained to check on R1 every 2 hours. R1 independently transferred to and from bed and used a cane or walker to walk. R1 was able to determine their pain levels and need for medication. Review of R1’s medical records indicated they had a T12 vertebra compression fracture as of 09/27/24. Review of incident reports revealed R1 fell on 03/03/25, 03/24/25, and 03/25/25. Interview with R1 at 1:25 p.m. on 04/24/25 revealed no pertinent information as R1 could not recall any fall at the facility. Interview with Staff #4 (S4) at 9:40 a.m. on 06/04/25 revealed R1 reported arm pain but no back pain after their 03/03/25 fall. Interview with Staff #1 (S1) at 11:15 a.m. on 05/21/25 revealed R1 did not report back pain after their fall on 03/24/25. Interviews with Staff #2 (S2) at 12:50 p.m. on 05/21/25 and Staff #3 (S3) at 9:10 a.m. on 06/04/25 revealed R1 reported having back pain after their fall on 03/25/25. Interview with R1’s family member (F1) at 8:25 p.m. on 04/28/25 revealed they requested R1 be hospitalized on 03/25/25 due to R1’s multiple falls within the month and irregular behavior. Review of an LAFD patient report from 03/25/25 confirmed R1’s lower back pain. Hospital records from R1’s hospitalization on 03/25/25 at Providence Cedar-Sinai Tarzana revealed R1 had a history of osteoperosis and dementia. An x-ray performed on R1 revealed no cervical spine fractures, however no x-rays were taken of R1’s thoracic or lumbar spine that day. R1 was diagnosed with a urinary tract infection (UTI). R1 returned to the facility on the evening of 03/25/25 with antibiotics to treat the UTI. R1 fell again on 03/26/25, and interview with Staff #5 (S5) at 10:10 a.m. on 06/04/25 confirmed R1 had back pain on 03/25/25 and again on 03/26/25. Interviews with Staff #6 (S6) at 2:20 p.m. and Staff #7 (S7) at 2:45 p.m. on 06/24/25 also confirmed R1 had back pain after a 03/26/25 fall. Interview with Staff #8 (S8) at 10:35 a.m. on 06/04/25 revealed R1 fell again on 03/27/25 and refused care from caregivers and family. S8 also noted that R1 was not walking and using a wheelchair since 03/25/25. Interview with the Care Coordinator at 11:25 a.m. on 06/04/25 revealed R1 may have fallen frequently due to their UTI. Additionally, the discharge paperwork from their 03/25/25 hospitalization did not mention a fracture. The Care Coordinator was not aware of R1 having back pain until 03/28/25 and stated it was not reported to them previously by staff. Interviews with the Marketing Director at 11:05 a.m. on 06/24/25 and the administrator at 3:05 p.m. on 06/24/25 concurred that R1’s pain on 03/26/25 was likely the result of their UTI from the previous day. Thus, they both did not feel the need to send R1 to the hospital. F1 had a telehealth visit with R1’s physician on 03/28/25 and was informed that R1 was on the wrong medication. F1 requested R1 be sent to the hospital that day. Review of CT Scan and medical records from R1’s hospitalization on 03/28/25 at UCLA West Valley Medical Center indicated R1 had an acute L1 vertebra fracture and further compression of the T12 vertebra. Based on observations, interviews, and record review, staff were aware of R1 having back pain on 03/25/25 through 03/27/25. R1 was not reevaluated by staff or medical professionals until 03/28/25 at the request of their family member F1. Only then were their fractures discovered. The Care Coordinator did not reassess R1 or seek further medical attention for their reported pain on 03/26/25 and 03/27/25 and therefore the allegation is deemed SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). No other immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.