complaint·February 19, 2025

On September 11, 2024, R1 was found by Staff 1 (S1) at approximately 1 PM laying on their bedroom floor. S1 reported they had heard R1 calling for help prompting their response. Upon finding R1, facility staff sought emergency medical services. R1 reported they were attempting to reach for their walker when they fell. S1 reported last observing R1 at 12PM, approximately an hour earlier, when they had passed out medications. Upon being admitted to Norwalk Community Hospital, R1 was diagnosed with facial contusions, knee abrasions and forehead hematoma. R1 reported to hospital staff they had fallen after reaching for a napkin. Due to inconsistency in R1’s report and injuries observed, Santa Ana Police arrived to speak with R1. Per Santa Ana Police report, R1’s injuries appeared consistent with injuries sustained from a fall. R1 reported being beaten by “four women” but was unable to provide further elaboration. The Department attempted a separate interview with R1 but was unable to due to R1’s cognitive decline. R1 did not appear oriented to time and space. Interviews with four of four staff reported R1 was independent prior to fall and received hourly to bi-hourly checks. Staff reported being aware R1 was a fall risk. The facility provided R1 with a fall matt and a call light to ask for assistance when needed. Interviews with R1’s nurse practitioner revealed no concerns of neglect. Per interview with R1’s responsible party, no concerns with R1’s care were expressed. Based on interviews conducted and records reviewed, the allegations that Resident sustained unexplained injuries due to lack of supervision and Resident sustained unwitnessed fall due to lack of supervision is deemed to be Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. This agency has investigated this complaint. An exit interview was conducted and a copy of this report and confidential names list was provided to facility representative.