complaint·January 15, 2025

Allegation: Staff left resident on floor for an extended period of time Investigation Finding: Substantiated During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. Review of R1’s admission agreement showed he was first admitted at the facility on 11/25/24 in the Memory Care unit with a primary diagnosis of dementia. Responsible party (POA) stated that on 11/29/24 at approximately 11:30PM, she received a couple of voice messages from staff (S1) advising her that R1 had an unwitnessed fall in his room at around 10:30PM, was confused & lethargic and had blood on his left elbow. Review of hospital discharge summary report dated 11/30/24 to 12/07/24 showed R1’s was admitted for altered mental status due to dementia precipitated by dehydration rhabdomyolysis (muscle weakness due to a fall & can’t get up for an extended period of time). POA stated that R1 goes to bed at around 8PM daily. Review of incident report dated 11/29/24 showed R1 had an unwitnessed fall on 11/29/24 at around 10:30PM when the night shift staff conducted their status check rounds in the memory care unit. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff left resident on floor for an extended period of time was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Staff did not ensure resident was hydrated resulting in dehydration Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible party and reviewed resident (R1) documents. LPA interviewed staff (S2, S3) who stated that R1 was independent with his daily meals and was observed to eat and drink water & juice during mealtimes (3X per day) and offered drinks with snacks at 10AM and 2:30PM daily. They stated they offered him drinks frequently but sometimes he refused since he did not feel thirsty. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure resident was hydrated resulting in dehydration and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure resident was hydrated resulting in dehydration is unsubstantiated. Allegation: Staff did not communicate with resident’s responsible party Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (S2) who stated that they communicated with R1’s responsible party (POA) regarding R1’s behaviors (being quiet, wandering with coat under arm wanting to go home, un-witnessed fall and ER hospital visit on 11/29/24. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not communicate with resident’s responsible party and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not communicate with resident’s responsible party is unsubstantiated. Exit interview conducted and a copy of this report provided.