Kindred Healthcare Center Of Orange
920 West La Veta Avenue, Orange, CA 92868
Citation Number: 060006849
Citation Date: 01/20/2010
Violation Date: 2/16/2010
Class: AA
Penalty: $ 85,000

A resident died on 7/18/09 four days after suffering a fall and fatal head injuries. The resident had a history of falls before and after entering the facility and a history of brain surgeries that put him at high risk of injury due to falls. His care plan called for preventative measures, including use of a personal alarm and a padded mattress next to his bed. Neither measure was in place when he fell on 7/14/09 and was found lying on his back on the floor beside his bed. The resident's daughter reported the facility staff disregarded his safety and told the investigator, "We went over and over this with facility staff members... they knew how important it was that he did not fall." The facility was cited because its failure to plan the resident's care and implement safety measures led to the resident's death.