Complaint·March 25, 2026

Resident R1 was admitted to the facility on September 30, 2013 with a primary diagnosis of hypertension and no initial indication of major neurocognitive disorders at the time of admission. R1 was discharged from the facility on January 9, 2024. Regarding the allegation that Staff neglect resulted in a resident sustaining an injury from multiple falls: Based on the evidence gathered, there have been multiple instances of fall incidents sustained by R1, at least one of which resulted in injury and hospital treatment. The evidence gathered is however insufficient to clearly establish that the falls were attributable to staff neglect rather than to changes in the resident’s condition. The allegation is therefore found to be Unsubstantiated. Regarding the allegation that Staff left a resident unattended while being transported to the hospital, the following has been concluded: After a fall sustained on December 8, 2023, R1 was first transported via EMS to Hoag Hospital in Irvine before being transferred to Hoag Hospital Newport Beach at the neurosurgery department due to a suspicion of a subdural hematoma. A review of the resident records maintained at the facility also allowed LPA to corroborate that the responsible party for the resident had been contacted by the facility staff following the fall. A fax reporting the fall to the resident's physician was also located. Report states that EMS had initially informed the facility that the resident would be transported to Saddleback MemorialCare but was re-routed to Hoag Irvine for unknown reasons which appears to explain why R1’s responsible party had to actively attempt to locate the resident following admission. A copy of R1’s Consent for Emergency Medical Treatment was present and on file. As resident was placed under the responsibility of EMS personnel, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. Resident R1 was admitted to the facility on September 30, 2013 with a primary diagnosis of hypertension and no initial indication of major neurocognitive disorders at the time of admission. Subsequent appraisals were conducted and reviewed, including updates to R1’s plan of care dated June 22 and August 23, 2023. Per a review of available charting notes, over a period starting in May 2023 and ending with the resident’s discharge in January 2024, R1 sustained at least five separate fall incidents. A significant bruise on R1's buttocks was reported to the family and primary care provider on August 25, 2023 with no ability to clearly determine the origin of the bruise. On that day, R1 was sent to Mission Hospital via 911 for generalized weakness and low food/drink intake and diagnosed with acute kidney injury. No report on file submitted to the Orange County Regional Office. Another reported fall occurred on November 7, 2023, with facility staff indicating resident had lost their balance but were assessed to not present any injury or pain. Fall also not reported to the Department of Social Services per a review of Incident Reports on file. R1 sustained another fall on December 8, 2023 and was first transported via EMS to Hoag Hospital in Irvine before being transferred to Hoag Hospital Newport Beach at the neurosurgery department due to a suspicion of a subdural hematoma. A review of the resident records maintained at the facility also allowed LPA to corroborate that the responsible party for the resident had been contacted by the facility staff following the fall. A fax reporting the fall to the resident's physician was also located. Report states that EMS had initially informed the facility that the resident would be transported to Saddleback MemorialCare but was re-routed to Hoag Irvine for unknown reasons which appears to explain why R1’s responsible party had to actively attempt to locate the resident following admission. Finally, another fall incident, this time not resulting in significant injury also appeared to be documented on January 8, 2024 and reported to the resident's primary care physician and responsible party but not to the Department of Social Services. R1 were discharged to their authorized representative on January 9, 2024. Regarding the allegation that Staff did not provide adequate care and supervision to a resident, the following has been concluded: Despite multiple occurrences of fall incidents sustained by R1, the individual needs assessments conducted by facility staff on June 22 and August 23, 2023 fail to document the fact that the resident was at risk for falls. Furthermore, the evolution of R1’s Mild Cognitive Impairment to a documented diagnosis of dementia was not apparent in the physician until after the resident was hospitalized, in spite of signs and incidents occurring in the months leading to the emergency hospitalization. Continued on LIC9099-C Regarding the allegation that Staff did not properly report incidents involving a resident, the following has been concluded: No reports were made to the Orange County Regional Office during any of the documented fall or hospitalization incidents sustained by R1 in 2023 and 2024. As a result, both allegations are found to be Substantiated, meaning that the preponderance of the evidence standard has been met. Two deficiencies to Title 22 requirements are being cited on an attached form LIC9099-D . An exit interview was conducted and a copy of this report was provided to a facility representative.