complaint·May 6, 2021

The investigation revealed the following: Residents did not receive personal mail It was alleged that resident's mail was backed up and staff were not distributing mail to residents in a timely manner. During the observation, LPA did not observe undistributed mail. When interviewed, the administrator stated that usually residents get their mail daily but admitted that, during the pandemic, mail had not been distributed in a timely manner. She stated that there was no designated person assigned to distribute it and that all staff are responsible. S1 and S2 stated that residents get their mail daily and they assist with sorting out the mail. S4 stated that when she came back from being on leave in December 2020, she noticed a large amount of undistributed mail in boxes and that she was tasked to distribute it when she returned. S5 stated that before pandemic, residents were getting their mail daily, but during the pandemic he was unsure if it was being distributed daily. S1 and S4 said that some residents have complained about not getting their mail. R1 stated that he receives his mail everyday or every other day. Staff did not prevent residents from wandering The administrator acknowledged that R1 had a history of wandering away from the facility but stated that he no longer lives at the facility. She stated that the resident liked to wander and she assigned staff to walk him three times a day. However, she stated that when she was out sick in December, no staff knew to take him for walks which led to him wandering alone. S1 stated that due to R1's history of wandering, they began doing 1 on 1 supervision after the incident on 12/26/20 where police found him in the community at 2 a.m. S1 also stated that on 12/27/20, an in-service training was completed for all staff and the 2 staff on-duty that night were terminated. S2 and S4 also confirmed R1's tendency to wander while S5 was not aware of residents wandering. R1 and R2 did not recall any instances of wandering away from the facility. A review of incident reports for R1 reveals that he wandered on 12/26/20 and again on 12/29/20. On 1/17/21, family members decided to move him out of the facility. R1's physician's report state that the resident has mild cognitive, visual, and motor impairment. The Needs and Services plan states that staff should assist him with taking walks daily. Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. CCR Title 22, Division 6, Chapter 8 is being cited on attached LIC9099D. An exit interview was conducted and copy of this report and appeal rights provided. The investigation revealed the following: Staff did not properly report incidents involving residents while in care LPA Spencer reviewed all incident reports for R1-R3 from December 2020-January 2021. Incident reports were received regarding R1's unauthorized absences from the facility on 12/26/21 and 12/29/21, R2's fall on 1/5/21, and R3's hospitalization on 1/3/21. In an interview, R2 stated that he has had falls at the facility but nothing serious and staff assisted him each time. Upon review of the dates of the incident reports, all incident reports were sent within 7 days of occurrence. In interviews, staff stated that they report all incidences to the administrator and the administrator or lead staff send the incident reports to licensing within 7 days. The administrator and S1 stated that they send incident reports and have trained the lead staff on sending incident reports when they are not at the facility. Staff did not have planned activities for residents Staff were interviewed and all stated that during COVID-19 pandemic, there were no communal planned activities. The administrator stated that the activities director was out sick in December and there were no planned group activities during this time. However, S1 stated that there were individual activities provided for residents in their room. She stated that now that quarantine is over for most residents, they have resumed group planned activities for residents. S2 stated that there are planned activities such as prayer, exercise, outings to the store, art, and movie nights. He stated that during quarantine, residents were provided individual activities such as activity books, word searches, and drawing. LPA reviewed the Activities Calendar from January 2021 and it revealed a variety of planned activities. LPA also reviewed the training log showing that staff were trained on helping residents with mental/physical stimulation during COVID-19. R1 and R2 interviewed and stated that there are a variety of activities including music, dancing, and games. Staff not able to assist residents with dementia LPA Spencer reviewed the Physician's reports and Needs & Services plan for R1-R3 and none were listed as having dementia but R1 and R3 have mild cognitive impairment. The administrator and staff stated that there are no residents with formal diagnosis of dementia. S1, S2, and S5 said that they have received training on caring for residents with dementia. R1 and R2 stated that they were unaware of any residents having dementia. Based upon interviews and records reviewed, the findings indicate that although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated. A telephonic exit interview was conducted, a copy of the report was emailed, and staff was instructed to sign and return to LPA.