Complaint·April 23, 2025

. Resident 2 (R2), who shares a room with R1, reported witnessing R1 fall from R1’s wheelchair on 02/09/25. R2 stated that R2 immediately sought assistance from facility staff 1 (S1), who responded and attended to R1. Despite the fall being unwitnessed by staff, the facility contacted emergency medical services on 02/10/25, and R1 was transported to Kaiser South for evaluation. According to R1’s After Visit Summary from Kaiser, R1 was admitted on 02/10/25 for a fall with a discharge date of 02/12/25. Medical documentation noted: “No acute hemorrhage. No mass effect or herniation. No acute intracranial injury.” The facility’s Plan of Operation outlines that emergency medical services (911) will be summoned immediately if a resident shows sign of distress (e.g., shortness of breath, chest pain, changes in consciousness). For non-serious emergencies, as determined by the administrator or supervisor on duty, the resident will be treated with first aid. In this case, the facility followed protocol and R1 assessed R1 during the fall and R1 was provided medical attention the next day. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation us UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.