The details of the complaint alleged that the resident (R1) sustained an unexplained injury while in care. It was reported that the resident had a fall and fractured their hip. On 07/16/25, from 9:00am-02:00pm, the department interviewed staff (S1-S5) witness (W1), and residents (R1-R5) about the allegation. 4 of 5 staff denied the allegation that Resident sustained an unexplained injury while in care. The majority of the staff stated that the resident was non-ambulatory and had a fall trying to get out of their wheelchair. S3 stated that they found R1 on the floor and asked what happened? S3 stated that R1 said they tried to get out of the chair and fell. S3 stated that they asked if R1 was in pain, and R1 said yes, so they sent R1 to the emergency room. Staff stated that the resident did not have a history of falling in the facility.

The department interviewed witness (W1) and residents (R1-R5) about the allegation. Witness (W1) stated that they were concerned because R1 had a fall but did not know what happened and was concerned for their safety while living at the facility. 4 of 5 residents that were interviewed stated that they have never sustained any injuries at the facility and did not witness or experience any physical abuse from the staff. They further stated that they did not have any concerns about living in the facility and felt safe with the staff.

The department reviewed the Physicians Report (Dated: 07/22/2024), Resident Appraisal Information (Dated:07/22/2024), Unusual Incident/Injury Reports (Dated: 10/14/2024) and observed that there was no history of falling at the facility. The department also reviewed the So Cal Hospital at Hollywood Medical Record (Dated: 10/28/2024) and observed that R1 was admitted for right hip pain from fall transferring from wheelchair. The department did not observe any other medical records or appraisals that would suggest R1 was a fall risk.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Resident sustained an unexplained injury while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur because of neglect, therefore the allegation is Unsubstantiated.

No citations were issued.

An exit interview was conducted with Terri Han, Assistant Manager, and a hard copy of this Complaint Investigation Report was provided.