complaint·August 20, 2025

presented in the emergency room (ER) with an “altered mental status, fatigue and generalized weakness…” R1 was diagnosed with sepsis. Interviews with staff noted that R1 would refuse treatment. Facility documentation notes that staff checked on R1 when they observed a change in condition. It was unclear if R1 developing sepsis was due to staff not obtaining timely medical attention or due to R1’s refusal for treatment. Due to these inconsistencies, there was not a preponderance of evidence to substantiate that hospitalization was a result of lack of care and supervision. The allegation was UNSUBSTANTIATED and no deficiencies were cited. Exit interview was conducted with Executive Director and a copy of this report was provided. well, experiencing weakness, confusion and runny nose. On 11/06/2024, at 6:30 PM, R1 was seen by paramedic due to weakness and back pain. R1 refused to go to the ER. On 11/07/2024 at 12:29 PM the home health agency providing services to R1 called 911 due to R1’s weakness and confusion. Staff became aware of R1 having a change in condition on 11/5/2024. Staff interviews and facility notes do not show that staff contacted R1’s primary care provider (PCP) when the change of condition was noted.  Based on documentation and information provided through interviews there was a preponderance of evidence to show that the facility did not properly assess resident and did not report the change in condition to PCP as required and therefore this allegation is SUBSTANTIATED. It was alleged that “Facility did not allow resident to come back to the facility after being hospitalized.”  Per facility documentation dated 11/18/2024 at 3:18PM, the facility was notified that R1 would be discharged back to Eskaton Gold River the following day on 11/19/2024.  On 11/19/2024, the Resident Care Coordinator (RCC) for the facility called the hospital requesting that R1 be transferred to a skilled nursing facility for rehabilitation, stating that R1 has to be able to bare weight otherwise R1 is not appropriate for the facility.  The facility should have allowed R1 to return home as the hospital stated that R1 needed a 2-person assist, and not any mechanical interventions/accommodations.  The facility refused.  The facility should have allowed R1 to return home, re-assessed R1's needs, and updated R1's care plan. If after a thorough assessment, it was determined that the facility could not continue to meet R1's needs, the responsible party should have been notified.  An updated care plan should have been created and a draft of a 30-day eviction letter stating that the resident required a higher level of care, along with supporting documentation, should have been submitted to Community Care Licensing for review.  The facility should have also assisted the resident and their responsible party in locating an appropriate placement, as required. Based on documentation and information provided through interviews there was a preponderance of evidence to show that the "Facility did not allow resident to come back to the facility after being hospitalized," and therefore this allegation is SUBSTANTIATED. Exit interview was conducted with AD Alfredo Cruz and a copy of this report was provided along with APPEAL RIGHTS.