Complaint Investigation Report

Allegation: Staff retained resident requiring a higher level of care

On 01/13/2025, Licensing Program Analyst (LPA) interviewed Witness 1 (W1), who stated that they began receiving multiple bills from ambulance services and hospital visits that they were unable to pay. W1 reported that they were not the one contacting 911 or sending Resident 1 (R1) to the emergency room (ER). W1 stated that R1 was sent to John Muir Hospital in Concord because R1 “wasn’t listening.” W1 further stated that R1 had been diagnosed with frontal lobe dementia, which required a higher level of care than what the facility could provide. W1 further stated that when R1 went to John Muir Walnut Creek he was sent back to the facility on hospice because they think the "idea to not send him back and that John Muir doesn't want to keep seeing him constantly." W1 stated that R1 was only on two types of meds and once he got on hospice, seven more types of medications were added.

LPA reviewed R1’s Physician’s Reports (dated 08/14/2024 and 11/06/2024), which indicate a diagnosis of possible frontotemporal dementia , with additional notes reflecting behavioral disturbance and advanced dementia , respectively. Record review showed a change in R1’s condition, with documentation of increased confusion, disorientation, refusal or forgetfulness in following instructions, and episodes of aggressive behavior. The Pre-Admission Appraisal (dated 10/22/2024) notes “Higher level of care” for Question #1. Despite these findings, the overall Care Plan identifies R1 as mostly independent in activities of daily living. LPA reviewed that 911 was called 10/28/24 and 11/10/24 per internal incident reports.