Complaint Investigation Report

According to facility records, several falls were documented--in March 2022, February 2023, April 2023. Client did not sustain any significant injuries as a result of these falls; he was evaluated at the hospital after April 2023 fall and released the same day.

Client was not under direct staff supervision on 5/29/23 when he fell in the common living room of memory care unit and sustained an acute shoulder separation. Client was evaluated and treated at the hospital.

On 6/27/23, client was observed to be unresponsive with low oxygen level. 9-1-1 was called and client was transported to hospital, where tests revealed he was severely dehydrated and significantly hyperglycemic. Client was admitted to ICU with severe sepsis and hypernatremia. Based on staff interviews, client missed 3 meals immediately prior to hospitalization, only one of which was documented. In addition, client was known to be always eager to eat, so his refusal to eat was unusual. Staff failed to accurately document the change in condition. report this to client's family and seek medical advice.

Deficiencies of the California Code of REgulations, Title 22 are cited on a following page, as well as civil penalties of $1000-- $500 for Section 87464 Basic Services and $500 for Section 87466 Observation of Resident. Assessment of additional civil penalties is pending.