complaint·November 9, 2021

***Continued from 9099*** R1's pre-appraisal indicates 2 hour checks, however the facility conducted 1 hour checks due to R1 being sedated with Ativan prior to being admitted on 10/16/21. The facility also wanted to ensure a better transition for R1. R1 sustained two falls on 10/17/21. The second fall resulted in R1 hitting their head, therefore R1 was taken to the hospital for evaluation. The facility decided that it was in the best interest of R1 to be taken to the hospital and not to wait until hospice arrived. R1's responsible party picked R1 up from the hospital and took R1 back to Pacifica Senior Living Hillsborough. The responsible party was aware that R1's Legacies memory care room would not be available until 10/18/21 or 10/19/21. R1 went home with the responsible party on 10/17/21 and did not return. The responsible party provided a 30-day notice on 10/19/21. R1 passed away at home with family on 10/20/21. An interview with the memory care director, revealed staffing was not insufficient in the transitional memory care unit on 10/17/21. From 10:00PM- 6:00AM there was 1 caregiver to 22 residents. From 6:00AM- 2:00PM there were 3 caregivers and 1 med tech to 22 residents. R1 should have been housed in the Legacies memory care unit where the staffing to resident ration is 2 caregivers to 10 residents in the day and 1 caregiver to 10 residents at night. Both allegations have been found to be substantiated. Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC9099D. An exit interview was conducted where this report, 9099D, LIC 811 and appeal rights were provided to the ED