complaint·May 16, 2025

During the investigation of a complaint received on 09/20/24, it was reported that the resident (Resident 1) pressed their pendant for assistance and when staff arrived the resident was observed on the floor lying on her back. It was stated that the resident independently tried to get out of her wheelchair and fell to the floor. The resident complained of back and hip pain and was sent by emergency services to the hospital. It was reported that the resident suffered a Lumbar Compression Fracture; however, it was not due to a lack of care and supervision. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated . Resident sustained multiple falls due to lack of supervision . During the interview process, the Resident Care Coordinator, the resident (Resident 1), and several staff persons were interviewed. In addition, documents were reviewed and obtained to include Personnel Report, Physicians Report, Emergency Information, Admission Agreement, Appraisal and Needs, Medication Administrative Record (MARs), Incident Reports and Medical Records. During the investigation of a complaint received on 09/20/24, it was reported that the resident (Resident 1) would independently page for assistance at times; however, other times, they would try and stand on their own and then fall. Documents reviewed, indicated that staff were available to assist the resident when they needed assistance or paged them. Falls were not due to a lack of supervision. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated . Licensee/health and wellness director was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. The licensee/health and wellness director is to sign and return a copy to the Orange County Regional Office.