complaint·March 24, 2026

medication. Although R1 had complex medical conditions, including liver cirrhosis, anemia, interstitial lung disease, and later hepatic encephalopathy, there was no physician designation indicating R1 was a fall risk. Facility records such as staff progress notes show that R1 experienced a significant and progressive decline in medical condition, including confusion, disorientation, weakness, and repeated hospitalizations. Documentation reflects that R1’s condition worsened following hospital discharges, particularly after episodes related to elevated ammonia levels and liver disease complications. The facility appropriately updated R1’s Personal Service Plan (PSP) multiple times (05/13/22, 05/18/22, and 05/23/22) in response to their changing condition. These updates included added assistance with medication management, dressing, grooming, and toileting. Although escort mobility assistance was briefly implemented and later removed, documentation supports that services were adjusted based on observed needs and condition changes. Incident reports indicate that R1 experienced multiple falls, many of which were unwitnessed or occurred while attempting to act independently, such as trying to get into bed or ambulate without assistance. Injuries documented were generally minor with skin tears and bruising, and staff responded appropriately by providing first aid and seeking medical evaluation when necessary. Medical records from Orange Coast Memorial indicate that at the time of hospitalization, R1 was alert, oriented, well-developed, and non-toxic appearing, with no signs of neglect. After the fall, a brain bleed was suspected, but R1’s decline was mainly caused by pneumonia, respiratory failure, and septic shock, which led to their death. The medical records review does not indicate or specify correlation between R1’s falls and her overall medical deterioration or death. Instead, documentation supports that their decline was primarily due to underlying chronic and acute medical conditions. In the medical records, it was also notated that R1’s family expressed satisfaction with the facility’s care and denied any concerns regarding staff. LPA conducted interviews with current facility staff who worked when R1 was present at the facility. All staff interviewed consistently reported that R1 experienced a noticeable decline in condition, including increased confusion, weakness, and frequent hospitalizations. Staff indicated that R1 preferred to maintain independence and often attempted tasks without assistance, which contributed to their falls. Staff also stated that R1 did not like to ask for help. All interviewed staff reported that they provided appropriate care and (Complaint investigation continued on LIC9099C) supervision, monitored R1’s condition, and responded to incidents as they occurred. Staff further indicated that R1’s sister expressed appreciation for the care provided and felt reassured by staff support. Although R1 experienced multiple falls while residing at the facility, the evidence supports that these incidents were largely associated with R1’s declining medical condition and attempts to remain independent, rather than neglect or lack of care by facility staff. The facility responded appropriately by updating care plans, monitoring R1’s condition, and ensuring medical attention when needed. Therefore, based on the records reviewed and interviews conducted, there is insufficient evidence to conclude that the facility’s actions directly caused or contributed to serious injuries resulting from the falls. The allegation mentioned above has been determined 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. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report and confidential names list were provided to the facility.