complaint·March 23, 2026

On 12/19/25, The department requested medical records from Northridge Hospital Medical Center and Health Corners Hospice Medical Records, California Department of Public Health Death Certificate and Los Angeles County Medical Examiner-Coroner Records. On 12/22/25, medical records from Northridge Hospital Medical Center were received. On 12/29/25, Health Corners Hospice Medical Records were received. On 01/12/26, the California Department of Public Health Death Certificate was received and on 01/26/26 the Los Angeles County Medical Examiner-Coroner Records were received. Regarding the allegation: Staff neglect led to resident death. It is being alleged that staff did not properly address resident #1 (R1)’s fall risk, which led to their death. The investigation included interviews with facility staff, residents, R1’s daughter, R1’s nurse practitioner, and physician, as well as a review of medical, coroner, and facility records. R1 entered the facility on 08/12/2025 and had two unwitnessed falls before their death on 09/23/2025. The first fall on 08/22/2025 caused a sprained ankle; the second on 09/19/2025 caused an intracranial hemorrhage. Post Fall Assessments were completed after each incident, and R1’s Needs and Services Plan documented their need for assistance with ambulation and all activities of daily living (ADLs). R1’s resident assessment, completed before admission, also addressed these needs. After the first fall, a staff member placed a foam mat around R1’s bed as a precaution. Staff consistently reported they were aware of R1’s fall risk. On the evening of the second fall, another staff member monitored R1’s due to their restlessness and checked on them frequently; R1 was found on the floor approximately 15 minutes after being returned to bed. 911 was called immediately. Hospital and coroner records confirmed an intracerebral hemorrhage from a ground-level fall. R1’s physician, and R1’s nurse practitioner, and facility staff explained that falls cannot be entirely prevented in seniors with their conditions. Based on the precautions taken and the available evidence, the fall was determined to be accidental, and the allegations of neglect/lack of supervision were found to be unsubstantiated. LIC 9099C-continued Regarding the allegation: Staff did not adequately address resident's fall risk. It is being alleged that resident #1 (R1) fell twice and the facility did not address R1’s fall risk. The investigation examined the allegation that staff neglect resulted in R1’s death. The investigation included interviews with facility staff, residents, and R1’s medical providers, as well as a review of medical, coroner, and facility records. Following both falls, staff implemented additional safety measures. R1’s physician stated, “that seniors, especially those with the medical conditions R1 suffered from, such as Dementia, were at increased risk of sustaining a fall that could be fatal.” R1’s Nurse Practitioner and facility staff all explained that it was impossible to prevent all falls. Due to all the precautions taken prior to R1 sustaining their fall, R1’s fall was determined to be an accident rather than the result of neglect. Therefore, the allegation of questionable death caused by falls were found to be unsubstantiated. Exit interview was conducted, no citation(s) were issued for the above allegation(s) and a copy of this report was given to the Executive Director.