Complaint·June 4, 2025

(continue from LIC9099) A review of R1’s most recent physician’s report from January 2025 and facility assessments indicated that R1 was considered fully independent and capable of making their own decisions. Investigation Findings A detailed review of R1’s medical records, hospital discharge instructions, and facility records revealed that R1 sustained a serious head injury from a fall in January 2025. Due to a change in condition and increased fall risk, R1 was discharged from the skilled nursing facility back to their apartment under a revised service care plan. This plan included 24/7 care and supervision, as well as physical therapy to aid in regaining strength and mobility. R1 agreed to retain a private duty aide (caregiver) to assist with activities of daily living (ADLs), such as dressing, bathing, and transfers, ensuring R1's health and safety. R1 was also subject to health and safety checks by facility staff to monitor any changes in condition, including daily check-ins with the private duty aide agency. This protocol was established by the facility for all residents, in compliance with Title 22 regulations, Division 6, Chapter 8, Article 08, which mandates regular observation of residents for changes in functioning and appropriate assistance when needed. The regulation (87466, Observation of the Resident) specifically outlines that the licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observations reveal unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or physical health condition are observed, the licensee must ensure that such changes are documented and brought to the attention of the resident's physician and responsible person. During interviews with staff and external sources, it was reported that access to R1’s apartment was being denied, preventing staff from conducting the required wellness checks. On May 16, 2025, facility staff knocked on the door, and when there was no answer, they announced themselves and entered to conduct the wellness check. Staff expressed concern that, despite multiple attempts to gain access, the 24/7 caregivers were instructed not to open the door to facility staff. On May 19, 2025, facility staff sought assistance by calling 911, prompting law enforcement to conduct the wellness check. (Continue at LIC9099C) (continue from LIC9099C) Staff stated during multiple interviews that during instances when the caregiver on duty did not open the door, staff announced themselves and entered R1’s apartment. In all cases, R1 was aware of the visits and had granted permission for the wellness checks. Conclusion Based on the investigation results, which included observations, interviews with key staff and external sources, and a review of pertinent resident records, there was insufficient evidence to support the allegation that staff violated R1’s privacy by entering the apartment after knocking and announcing themselves. Therefore, this allegation is deemed unsubstantiated. An unsubstantiated finding means that while the allegation may have validity, there is not enough evidence to conclude that the alleged violation occurred. An exit interview was conducted with Associate Executive Director Amy Patterson, who received a copy of this report, the Confidential Names List (LIC 811), and the Licensee Appeal Rights (9058 03/22) at the conclusion of the visit.