complaint·June 4, 2025

Allegation: Facility failed to meet the resident's needs. Unsubstantiated It was alleged facility failed to meet the resident’s needs, however, the department conducted staff interviews, reviewed R1’s assessments, and the care plan shows R1 does not need a one-on-one for all three R1 assessments, dated 10/2/2021, 2/17/2022, and 8/25/2022. However, R1 was to have 4 to 8 status checks per shift by a caregiver. After this incident, S3, S2, and S1 all decided to "have more eyes" on R1. "Having more eyes" means checking on R1 more. S6 told caregivers to watch R1 and R1's behavior. After R1 falls and R1 comes back from the hospital, the staff would monitor R1 more frequently and follow R1's discharge instructions During safety checks on R1, S9 would "pop in" the R1 room. Check to see if R1 was breathing or sitting. Checks were quick and lasted about two minutes. For the PM shift, S9 checks on residents about three to four times. S9 would always check on R1 before S9 left. Checks are not being documented. On 3/22/23 S6, S7, and S9 stated R1 refused to get change and bathing most time, and when R1 does want assistance, it depend on R1 mood. However, most time R1 doesn’t want to get assistant with ADL because to R1, R1 think R1 can still manage by R1 that R1 is still independent. Conducted interviews with S1, S2, S3, S4, S6, S7, S8, S9, S10, and HHN stated R1 is being checked 4 to 8 times, and always with a staff member. Report continues on KIC 9099c... Allegation: Lack of care resulted in resident sustaining multiple urinary tract infections. Unsubstantiated On 6/18/2021, R1 was admitted to the assisted living side of Carefield Castro Valley. R1 had been in and out of the hospital during R1's time at the facility. R1 was transported to Kaiser in San Leandro in January 2022, due to urinary tract infection (UTI), followed by COVID-19, and low platelets. Records reviews R1’s contacted UTI on 1/17/2022, 7/13/2022, and 8/23/22. However, before the three different events that R1 contracted, UTI S1 had requested R1 to get a check-up. S1, S6, S7, S8, and S9 encouraged R1 to drink more water, but R1 asked to be left alone. Staff stated they cannot force anyone to do anything they don’t want; they can only encourage. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report are provided. Based on interviews of staff at the Carefield Castro Valley facility, R1 was admitted on 6/18/2021 and was transferred from the Assisted Living side of the facility to the Memory Care side on 2/18/2022 because of R1’s dementia diagnosis and a recommendation from Kaiser Memory Care Clinic for R1 to be in Care. Memory Care staff and documents show a history of seven falls from 5/4/2022 to 8/17/2022. Staff statements show R1 was considered a fall risk and that R1’s condition had changed both mentally and physically. Staff statements confirmed that R1 believed R1 could stand up and walk without assistance, however, R1 would fall and sustain multiple unwitnessed falls while being in R1’s room. Staff were aware to frequently check on R1, however, R1 fell multiple times. S1 stated S1 would keep R1 with S1 while working because S1 wanted to keep a closer eye on R1, however, the evidence does not show S1 gave any instructions to direct care staff to provide care and supervision to R1 to prevent R1 from falling in R1 room. Although facility staff were aware of R1's multiple falls, they failed to take adequate measures to ensure R1’s safety, resulting in multiple falls and/or being found on the floor in R1's room. R1 was sent by the facility to Kaiser on 5/4/2022, 7/11/2022, 7/13/2022 (twice), 8/17/2022, and 8/23/2022. R1 was diagnosed with fractured ribs on 7/13/2022 and a fracture to the T9-T10 vertebrae on 8/17/2022. Based on evidence obtained during the course of this investigation, the Department has determined that lack of supervision resulted in resident sustaining multiple fractures from unwitnessed falls. This is a factual determination based on all the facts and circumstances of the case. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . Exit interview conducted. Appeal Rights and a copy of this report are provided.