The complaint alleges that Resident #1 (R1) screams for help and has fallen while at the facility. Record review revealed that R1 had moved into the facility on 11/22/2023 and shared a room in the Assisted Living side of the facility with their spouse. R1’s care plan upon admission included status checks, which were documented in the resident’s narrative charting. R1’s spouse moved out of the facility on 12/30/2023 and R1 continued to reside in the room in Assisted Living. On 02/16/2024, a new care assessment was completed for R1, which continued to indicate status checks for R1 were necessary. Incident reports reviewed revealed R1 was found on the floor on multiple occasions, but R1 was uninjured and refused to be sent to the hospital. Additional incident reports indicate that on 05/06, 05/07, and 05/09/2024, R1 refused or missed medications. R1’s physician and family were notified of the medication refusals. On 05/10/2024, R1 was moved to the memory care unit at the facility. Interview with staff revealed that the resident was receiving hospice care the entire time R1 resided at the facility; hospice aide provided bathing assistance to R1. Care staff was responsible for the remainder of R1’s ADL care, including but not limited to: assistance with dressing, grooming, and incontinence care. Staff stated staff checked on R1 every 2 (two) hours, as R1 was a potential fall risk and required regular incontinence care. Staff also stated R1 had a motion mat next to their bed that would alert staff when R1 was getting out of bed and after the mat was placed and the staff rearranged the furniture in R1’s room, R1 had less falls. Residents interviewed throughout the complaint investigation stated their care needs are met, and staff provide sufficient supervision. When R1 moved out of the facility, R1’s family member wrote a letter indicating “we were happy with the experience at Pacifica” and the move was to be closer geographically. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time.

Allegation: “Staff is not addressing resident’s need for a higher level of care:”

Record review revealed that upon moving into the facility, that R1 was identified as a level 7 for care, including status checks and 2-person assist for most ADL (activity of daily living) care. At that time, R1 was also receiving hospice services. R1’s physician’s report dated 11/20/2023 indicates R1 has a diagnosis of Alzheimer’s Dementia and hypertension, R1 can feed themselves, but required assistance with all other ADL

Report Continued on LIC 9099-C

Exit interview conducted. No citations issued. A copy of today’s report was provided.