Complaint·October 29, 2025

Additionally, The department has received statements by interviewed staff that R1 only had one significant fall prior to their death. Per staff statements R1 only had one fall which resulted in injury, the department received notification and documentation of fall and selected treatments that did not meet department requirements for further investigation. Staff interviewed provided statements that R1's decline and instability was addressed by increased checks and supervision and the implementation of a bed alarm that would alert staff members if/when R1 would attempt to get out of bed without staff assistance. All staff statements received were consistent with a resident on hospice and declining prior to death. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of (Questionable Death, Neglect/Lack of Supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.