complaint·May 20, 2022

Per reports, on 04/13/2022, Resident 1 (R1) was hospitalized after falling at Woodbridge Terrace. R1 was observed walking in the facility garden with their walker. Staff 1 (S1) was helping another resident when R1 tripped and fell back hitting their head against the floor. S1 called 911 and R1 was transferred to OC Global Hospital for further evaluation. S1 called R1’s daughter to notify of the fall and transfer to hospital. R1 was discharged from OC Global Hospital on 04/17/2022 and returned to Woodbridge Terrace Memory Care. Upon R1 returning from the hospital, the facility reported they have implemented the following fall preventative measures for R1: fall mats, 2 person assists, and enhanced hourly status checks. Per interview with staff pain medication were added to R1 medications. Interviews conducted with residents 3 out of 4 residents did not have concerns with lack of care and reported that staff treated them well. The 4th resident was unable to answer LPA questions due to not being alert to time and space. Based on health information dated 04/11/2022 R1 needs an escort to move about community. S1 was outside with R1 and another resident at the time of the fall. Based on an interview with R1 family, the family reported that R1 has had a history of falls in the past. Per physician wellness orders R1 is a fall risk and is not allowed lifting over 3 lbs. Therefore based on the preponderance of evidence gathered, interviews conducted, records reviewed and observations made the allegation that facility lacked care and supervision resulting in a fall are determined to be unsubstantiated, meaning, that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided.