Complaint·April 14, 2021

It was also alleged that R1 wandered away from the facility multiple times due to lack of supervision. LPA reviewed records which indicated R1 wandered away constantly. A caregiver noted on 8/17/19, that R1 "wonders to the point a private caregiver is in need". In the span of R1's eight days in the facility’s Memory Care Unit, it was noted numerous times R1 wandered the halls into other residents’ rooms and on multiple occasions, R1 was found wandering on the third floor which is part of the facility’s Assisted Living area. On 8/20/19, R1 eloped from the facility and was found by the Antioch Police Department a few blocks away from the community. Charting notes on 8/20/19, indicated R1 was last seen by staff at around 7:00 p.m. and staff did not realize R1 was missing until the Antioch Police Department made contact at around 8:00 p.m. Resident pre-admission records indicate facility was aware R1 had wandering behaviors and even after observing R1’s excessive needs, failed to provide increased supervision. It was also alleged that the facility’s alarm system for the Memory Care Unit exits were not working and/or construction workers propped doors open during construction projects. During LPA's walk-through of the facility on 8/23/19, LPA observed that in the Memory Care Unit on the second floor, there was a delayed egress door that allowed residents to go through a short hallway and into the enclosed outside area. In that same short hallway was a stairwell that went upstairs to the third floor where upon entry no alarms were set off. The third floor is an open area in the Assisted Living area which leads to the front entrance/exit. Per charting notes, R1 was found wandering on the third floor multiple times during R1’s stay. Based on all the information gathered, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22, Division 6 and Chapter 8 on the attached LIC9099-Ds. Exit interview conducted and a copy of this report and Appeal Rights provided. It was also alleged that staff did not meet resident's bathing needs. It is noted in the charting notes that R1's RP prefers for R1 to shower every day. It was alleged that R1 had not been given any showers during his stay at the facility. On R1's Needs and Services Plan, it is indicated that R1 will receive full assist with showers twice a week or as needed. During R1's stay at the facility from 8/13/19-8/20/19, it was noted by staff that R1 refused showers every day except on 8/18/19 where it's indicated that R1 had a shower that day. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.