Complaint Investigation Report

Resident 1 (R1) was admitted to Adult Care OC Saturna on August 11, 2021. The Admission Agreement was reviewed and showed a monthly private pay rate of $4,250 for a double room, and no preadmission fee was charged. Resident 2 (R2) and an additional family member are listed as R1’s responsible parties. R1’s Physician Appraisal Report dated July 13, 2021, has an indication of a dementia diagnosis for R1 and shows that R1 was assessed as being unable to manage their own cash resources due to prior stroke. R1 was additionally assessed to be unable to independently transfer to and from bed. R2 paid R1’s monthly rent. The licensee’s email dated April 29, 2024, stated R1 passed away on December 24, 2022, at the facility. No death report was submitted to the Department or provided to the resident’s attorney-in-fact at the time.

R2 was admitted to Adult Care OC Saturna on June 11, 2021. The Admission Agreement was reviewed. R2 was listed as self-responsible with a monthly private pay rate in the amount of $4,250 for a double room. A preadmission fee in the amount of $500 was charged. R2’s Physician Appraisal Report dated June 24, 2021, identified R2 had dementia and was unable to manage their own cash resources. A later Physician Appraisal Report dated December 6, 2022, stated R2 was non-ambulatory and had mild cognitive impairment and was unable to manage their own cash resources.

Regarding the allegation that Resident sustained an unexplained fracture while in care , the following has been concluded: R2 was admitted at Adult Care OC Saturna on June 11, 2021. Prior to the last unwitnessed fall on October 06, 2022, R2 was ambulatory and able to walk with no assistance. After the fall and hip surgery, R2 used a wheelchair for mobility. R2 had a history of falls prior to becoming wheelchair bound.

On or about October 6, 2022, at about 6 AM, R2 had an unwitnessed fall in their room. Staff 1 (S1) and Staff 2 (S2) found R2 on the floor, assessed R2 and placed R2 back in bed. Later that evening R2 complained of pain to their hip and was unable to walk. It is unclear whether staff notified R2’s responsible party. Department did not receive any incident report regarding the fall. Charting notes provided indicate that R2 had been monitored following the initial fall. On October 7, 2022, at about 6:30 AM, staff S1 transferred R2 from their bed to a wheelchair because R2 was still unable to walk, and informed S2 that a bruise was present on the resident’s left hip. Per notes reviewed, S2 asked R2 if R2 was in pain and the resident confirmed. Per statement made by facility acting administrator (AA) May Kwok, on October 10, 2022, at approximately 10 AM, a Hope Hospice nurse visited the facility and assessed R2 and reported that R2 was okay.