Complaint Investigation Report

During the course of the investigation, the Department conducted a file review for R4 and observed that R4 moved into the facility on June 21, 2023. The Department reviewed R4's Physician's Report dated May 19, 2023. Per R4's Physician's Report, R4 was diagnosed with dementia, was considered non-ambulatory, and was confused/disoriented. The Department reviewed the facility's progress notes for R4 between the dates of June 21, 2023, through April 30, 2024. The Department observed that during R4's stay at the facility between June 21, 2023, and April 30, 2024, R4 sustained a total of twenty five falls at the facility. The Department observed that R4 was hospitalized as a result of two of the falls. The Department reviewed R4's plan of care between June 21, 2023, and April 30, 2024. The Department observed that the facility stated that they will aim to minimize R4's falls through increased checks as needed. However, there were no other interventions or fall prevention techniques put in place to address this need. The Department also observed that R4 was not reassessed during this period, to determine if he required a higher level of care due to his falls. The Department attempted to conduct an interview with R4 for this allegation, however, R4 was unable to be qualified for an interview due to his cognitive condition.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the two allegations listed above. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D page. An immediate civil penalty is also being issued in the amount of $500.00. An additional civil penalty is pending determination by the Community Care Licensing Division under Health & Safety Code 1569.49(f). An exit interview was conducted with Resident Services Director Mirian Im and Executive Director Kip McMillan and a copy of the report was provided at time of visit.