complaint·April 22, 2025

Allegation: “Staff do not ensure adequate care and supervision is provided to resident:” The complaint alleges that Resident #1 (R1) screams for help and has fallen while at the facility. Record review revealed that R1 had moved into the facility on 11/22/2023 and shared a room in the Assisted Living side of the facility with their spouse. R1’s care plan upon admission included status checks, which were documented in the resident’s narrative charting. R1’s spouse moved out of the facility on 12/30/2023 and R1 continued to reside in the room in Assisted Living. On 02/16/2024, a new care assessment was completed for R1, which continued to indicate status checks for R1 were necessary. Incident reports reviewed revealed R1 was found on the floor on multiple occasions, but R1 was uninjured and refused to be sent to the hospital. Additional incident reports indicate that on 05/06, 05/07, and 05/09/2024, R1 refused or missed medications. R1’s physician and family were notified of the medication refusals. On 05/10/2024, R1 was moved to the memory care unit at the facility. Interview with staff revealed that the resident was receiving hospice care the entire time R1 resided at the facility; hospice aide provided bathing assistance to R1. Care staff was responsible for the remainder of R1’s ADL care, including but not limited to: assistance with dressing, grooming, and incontinence care. Staff stated staff checked on R1 every 2 (two) hours, as R1 was a potential fall risk and required regular incontinence care. Staff also stated R1 had a motion mat next to their bed that would alert staff when R1 was getting out of bed and after the mat was placed and the staff rearranged the furniture in R1’s room, R1 had less falls. Residents interviewed throughout the complaint investigation stated their care needs are met, and staff provide sufficient supervision. When R1 moved out of the facility, R1’s family member wrote a letter indicating “we were happy with the experience at Pacifica” and the move was to be closer geographically. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Allegation: “Staff is not addressing resident’s need for a higher level of care:” Record review revealed that upon moving into the facility, that R1 was identified as a level 7 for care, including status checks and 2-person assist for most ADL (activity of daily living) care. At that time, R1 was also receiving hospice services. R1’s physician’s report dated 11/20/2023 indicates R1 has a diagnosis of Alzheimer’s Dementia and hypertension, R1 can feed themselves, but required assistance with all other ADL Report Continued on LIC 9099-C care. R1’s physician did not indicate R1 wanders or has aggressive or inappropriate behavior. Upon reassessment on 02/16/2024, R1 was lowered to a level 5 care. Narrative charting for R1 indicated R1 refused medications on 3 (three) dates in May, as identified in the report above. R1 was then moved to the facility’s memory care unit on 05/10/2024 and a new care assessment was completed. R1 was lowered again to a level 4 care. LPA interviewed staff and management related to the complaint allegation. Interviews revealed that R1 did yell for assistance and staff stated this is not an uncommon behavior. When a resident is observed to have additional behavioral expressions or could potentially require a change in care, care staff will report to the med tech or a supervisor and a nurse will assess the resident. Then the facility communicates with the family to ensure the resident’s needs are met and consistency of care for the resident. In the case of R1, facility management was communicating with R1’s family member to arrange the finances and care as R1’s dementia progressed. R1 was moved to the memory care unit when the nurse and family agreed was appropriate for R1. R1’s family member then moved R1 out of the facility on 06/08/2024. While R1 did move to a facility that offers a higher level of care, R1’s family member stated they moved R1 to a facility closer to family and the same facility R1’s spouse was residing at. According to R1’s family member, R1 was moved into the other facility’s memory care unit, which offers the same level of care R1 was receiving at this facility. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. No citations issued. A copy of today’s report was provided.