complaint·June 19, 2025

[Continuation of LIC 9099] A staff interview and facility record review also revealed R1’s companion notified the facility that R1 had sustained a fall during an outing on that same day, December 10, 2024. A review of Outside Source1 (OS1) records dated December 11, 2024, disclosed R1’s fall resulted in a Traumatic Subdural Hematoma causing a significant change in condition. Upon discharge from the hospital and return to the community on December 11, 2024, R1 started to receive services from an outside agency. An additional interview conducted with Outside Source2 (OS2) corroborated R1 received services from an outside agency from 1:00pm to 5:00pm every day and is in process of obtaining additional services for R1. Interviews and record reviews revealed on March 28, 2025, facility management and R1’s Responsible Parties (RPs) met regarding R1’s need for a higher level of care, including medication management and fall prevention. Facility record reviews also confirmed facility Management is actively trying reach out to R1’s Primary Care Physician (PCP) for an updated Physician’s Report, and trying to work with R1’s RP to ensure R1 is receiving the proper level of care. Based on record reviews and interviews with facility staff and outside sources the above-mentioned allegation was determined to be Unsubstantiated. An Unsubstantiated finding means the preponderance of evidence to prove the violation occurred was not met. An exit interview was conducted with E.D. Guillen, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided. Signature below confirms receipt of the reports.