complaint·April 24, 2026

Regarding the allegation: “Staff did not provide timely medical care. This complaint alleged that staff did not seek timely medical care for R1 who was in pain after an unwitnessed fall. Record reviews revealed the following: R1’s Physician Report (dated 08/07/2023) indicates that R1 was diagnosed with mild cognitive impairment, was non-ambulatory due to physical condition and requires a walker. The facility’s incident report indicates that on 01/20/2025 at 11:45 a.m., R1 was observed screaming in pain after an unwitnessed fall. Staff assessed R1, and that 911 was not called. The Los Angeles Fire Department emergency response records indicate that first responders arrived at the facility at 5:02p.m. on 01/20/2025. Hospital medical records indicate that on 01/20/2025 at 5:29 p.m. R1 arrived and was diagnosed with a Fractured Back, Urinary Tract Infection and Brain Bleed. Interviews revealed the following: On 01/20/2025 around 11:30 am S6 reported hearing R1 screams for help from R1’s room. S6 informed S7 of R1’s fall, S7 evaluated R1 and noted complaints of pain to R1’s back, S7 gave R1 Tylenol and staff lifted R1 from the floor and placed R1 on the wheelchair. At around 2:00 p.m. S8 called W1 to report that R1 was in pain and that the pain increased. On 01/20/2025 at around 4:30 pm W1 found R1 screaming in pain and asked staff to call 911. It took approximately five and a half (5 ½) hours for R1 to get medical attention. Based on the records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation that “staff did not provide timely medical care” is found to be SUBSTANTIATED. Regarding the Allegation: Resident sustained a serious injury while in care. This complaint alleged that R1 sustained serious injuries while in care. Record reviews revealed the following: R1’s Physician Report (dated 08/07/2023) indicates that R1 was diagnosed with mild cognitive impairment, was non-ambulatory and requires a walker. The incident reports dated 12/13/2024 indicate that on 12/13/2024, R1 had unwitnessed fall, and R1’s doctor ordered R1 to be taken to the hospital. The incident reports dated 01/20/2025 indicate that 0n 01/20/2025, R1 had a second unwitnessed fall. On 01/20/2025 Hospital medical records indicate that R1was diagnosed with a Fractured Back, Urinary Tract Infection and Brain Bleed. Interviews revealed the following: On 12/13/2024 after hospitalization following an unwitnessed fall, R1 was not assessed for fall risks, and a fall ‑ prevention plan was not developed. On 01/20/2025 at 11:30 a.m. S6 heard a loud commotion and screams from R1’s room. S6 was concerned about R1 back as R1 states that their back hurt. S6 informed S7 of R1’s fall and S7 evaluated R1 and noted complaints of pain to R1’s back. S7 gave R1 Tylenol and did not call 911. W1 indicates that R1 was transported to the hospital only after W1 told staff to call 911. On 01/20/2025 at 4:30 pm W1 found R1 screaming in pain and asked staff to call 911. Based on interviews and record reviews conducted by CCLD staff for R1 the preponderance of evidence standard has been met. Therefore, the allegation that “Resident sustained a serious injury while in care” is found to be SUBSTANTIATED. Regarding the Allegation: Questionable death. This complaint alleged that resident sustained a questionable death, due to staff’s failure to reassess and implement fall interventions after R1 fall on 12/13/2024 and staff’s failure to provide timely medical care after R1s fall on 01/20/2025. Record reviews revealed the following: The facility incident report dated (01/20/2025) approximately 11:30 am indicates that R1 had an unwitnessed fall and facility staff did not call 911 or transport R1 to the hospital. The Hospital records dated 01/20/2025 indicate that R1 was hospitalized after R1’s falls while at the facility on 12/13/2024 and on 01/20/2025. On 01/20/2025 R1 was diagnosed with Fractured Back, Urinary Tract Infection and Brain Bleed. On 01/31/2025 hospital records indicate that R1 died in the hospital, R1’s primary cause of death was listed as Acute Subdural Hematoma, which is a collection of blood under the skull's outer lining (dura), caused by severe head trauma, leading to rapid pressure on the brain. R1’s Death Certificate dated 02/05/2025 indicates Hemorrhagic Storke or bleeding inside the brain as cause of death. Interviews revealed the following: On 01/20/2025 around 11:30 am S6 reported hearing R1 screams for help from R1’s room. S6 informed S7 of R1’s fall, S7 evaluated R1 and noted complaints of pain to R1’s back, S7 gave R1 Tylenol and staff lifted R1 from the floor and placed R1 on the wheelchair. At around 2:00 p.m. S8 called W1 to report that R1 was in pain and that the pain increased. On 01/20/2025 at around 4:30 pm W1 found R1 screaming in pain and asked staff to call 911. Based on the reviewed records and interviews conducted, the preponderance of evidence standard has been met. Therefore, the allegation "Questionable death” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is cited on the attached LIC 9099D. An immediate civil penalty is being assessed please see LIC421IM. At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(e) For a violation that the department determines resulted in the death of a resident. “ An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights was provided to Administrator Maria Galvan.