Complaint·September 26, 2024

Allegation: Staff did not honor restraining order for resident Investigation Finding: Unsubstantiated During investigation, LPA reviewed resident’s admission agreement dated 09/09/23 which showed he was first admitted at the facility on the same date. Review of R1’s physician’s report dated 07/18/23 showed R1 was diagnosed with dementia and should be escorted by staff due to cognitive impairment. However, review of R1’s latest physician’s report dated 01/31/24 showed R1 was ambulatory, in good physical condition and was able to leave the facility unassisted. On 12/19/23, Executive Director (ED) notified R1’s authorized representative (POA) that R1 left the facility in the company of another resident (R2) using her personal vehicle after ED advised R2 not to do so. A missing person's report was filed with the local police department. ED stated R1 and R2 returned to the facility on the same day, 12/19/23. Due to R2’s constant involvement with R1’s communications and finances, an Elder Abuse Temporary Restraining Order (TRO) was filed by R1’s POA and was granted by the Contra Costa County Superior Court. The TRO required R2 To stay at least 2 yards (6 feet) away from R1 and not to interfere with his finances or communications in any way. Family lawyer (FL) served R2 with the TRO effective 12/29/23 and emailed a copy to facility staff on 01/03/24. ED stated he met with R2 on 12/29/23, discussed the TRO and R2 agreed to honor the TRO. ED stated R2 was observed constantly out of the facility by staff to avoid seeing R1. Review of R2’s sign out records from 12/29/23 until 02/15/24 showed R2 left the facility frequently to spend more time with family and friends. On 02/18/24, R1 had a stroke and was sent to the hospital for treatment. On 02/24/24, R1 appointed his brother (W1) and granted W1 power of attorney for his medical and financial decisions. The hospital transferred R1 to a skilled nursing facility where his health continued to decline. R1 was later transferred to another skilled nursing facility and passed away on 06/22/24. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not honor restraining order for resident is unsubstantiated. No deficiencies cited during visit. Exit Interview conducted and a copy of this report provided.