complaint·March 24, 2026

PG. 2 On the allegation “Facility staff neglected resident contributing to questionable death” the following was found. R1 was admitted to the facility on 4/29/2024. On 8/8/24, the facility staff took over medication administration for R1 per their responsible parties request. On 8/27/24, R1 was having chest pains and was sent to San Ramon Valley Regional Hospital. R1 was diagnosed with low potassium. R1 was treated and sent back to the facility the same day with no new orders. On 9/11/24, R1 was having trouble breathing and was sent to the hospital on 9/12/24. R1 was diagnosed with low potassium levels and bloody fluid coming from the lungs. R1 was discharged from the hospital on 9/26/24. R1 did not return to the facility and was transferred to home health care at their responsible parties home. On 9/28/24, R1 was having shortness of breath and weakness and was transported back to the hospital while in their families care. On 10/4/24, R1 was transferred to a skilled nursing facility (SNF). On 11 /7/24, R1 was having trouble breathing while at the SNF. R1’s lungs were drained and appeared to be doing better. On 11/12/24, R1 tested positive for MRSA and went back to the hospital. R1 was placed on hospice and passed at the hospital on 11/17/24. It was alleged that Ivy Park San Ramon missed R1’s potassium medication however it could not be confirmed after a review of the Medication Administration Record (MAR ) For 7/01/2024-9/26/2024. R1 was also taking medication for congestive heart failure, medications were classified as a diuretic (water pill), a common side effect is a drop in potassium level (hypokalemia). According to Mayo clinic hypokalemia is, “Low potassium a condition in which the potassium level in your bloodstream is lower than is typical. The medical term for this condition is hypokalemia”. Report continues on LIC9099-C PG. 3 R1 also had a complex past medical history with comorbidities and was taking multiple medications as prescribed. A copy of R1’s death certificate revealed R1 passed away on 11/17/2024 at JOHN MUIR MEDICAL CENTER-WALNUT CREEK and the cause of death was listed as chronic respiratory failure and heart failure; the etiology is unknown. A causal connection could not be established between the care at the facility and R1s expiration. Therefore, the allegation “Facility staff neglected resident contributing to questionable death” is Unsubstantiated. 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 . No deficiencies cited. Exit interview conducted and a copy of this report provided.