complaint·May 4, 2023

9099C(1)... Resident (R1) moved to the facility on/around 7/13/22. Resident’s physician’s report, dated 7/6/22, notes resident has a diagnosis of Dementia, is confused/disoriented, is unable to leave the facility unattended and needs medication management due to Dementia. Pre-appraisal states that resident is ambulatory and is able to walk without any physical assistance and is able to mentally and physically follow signs. Pre-appraisal also notes that resident needs special observation/night supervision due to confusion, forgetfulness or wandering. Allegation: Staff did not provide adequate supervision resulting in resident wandering away from facility. Complaint alleges that resident was able to leave the facility unattended due to the alarm system not working and/or insufficient staffing. Staff interviews and resident charting notes document that resident first left the community unattended on 8/28/22 and again on 12/2/22. Charting notes entered on 8/28/22 note that at approximately 1:45 pm , resident left the outside garden area where she was sitting in memory care after eating her lunch. Notes also document that the Assisted Living Med-Tech heard on walkie that Memory Care caregiver announced that the alarm in Memory Care was going off and resident found way out of locked back gate in Memory Care and was walking up the hill. Charting notes entered later in the day on 8/2 8/22 indicate that “patio doors are locked so they will alarm if she goes out the back door…. Resident will need 1:1 care if she continues exit seeking behaviors”. All staff was advised to do frequent checks on resident to include how she is doing and her whereabouts". Charting notes entered on 12/2/22 document resident's elopement and resident's responsible person was notified by telephone voice mail and a return call was requested. Administrator stated that when resident eloped to the back enclosed parking lot, resident's 1:1 caregiver was talking to another caregiver and staff heard the delayed egress go off. Administrator confirmed there were (3) staff on shift and resident was never out of sight from staff and did not sustain any damage or injuries. Administrator confirmed an incident report (LIC624) was submitted to the Department following each elopement; however, a citation has not been issued. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C(2)... 9099C(2)... Allegation: Staff did not safeguard resident's personal items. Complaint alleges that (2) original oil paintings were missing upon resident moving out in January 2023. Resident’s representative/responsible person (RP)stated there were a total of (3) paintings that disappeared; however, the third one "suddenly appeared" on R1's bed when she was moving out on 1/6/23. described the painting as an epitaph of a Mexican man. RP stated he did not notice any of the (3) paintings to be missing until "about a week before moving out" on 1/6/23. RP confirmed the paintings were not documented in resident's initial inventory upon move in. RP stated to LPA on 2/6/23 that R1 valued the first painting at $5K and the second painting at $3K, totaling $8K. and that R1 has approximately 50 paintings of hers, and he has all but 2 currently in his possession. RP told LPA the one missing painting is of R1's mother's house and the second one is of an Afghan female woman with green eyes. RP indicated he did not file a police report at the time he noticed the paintings were not in R1's room, as he didn't think of it at the time, but later filed one on 2/14/23 and provided a copy to LPA. Memory Care Coordinator stated that "(R1) was a wonderful artist-- she had many loose canvasses and some were unframed and of different sizes-Some canvasses were under her bed and behind the bed and also a number of stacked paintings near the fridge". Administrator stated "missing paintings were never mentioned until move out" and RP visited resident regularly. The facility visitor log shows resident’s RP visited regularly from July 2022- January 6, 2023, for a total of approximately (31) visits. Progress notes, entered on 1/4/23, state that on 1/3/23, ,RP stated to MCC that a staff told him she saw another resident's family member walk away with the paintings. When MCC discussed this scenario with RP and the caregiver, the caregiver did not recall this conversation at all. Administrator confirmed the facility did not complete an initial inventory of R1's belongings, stating RP "waived it". LPA observed a blank LIC624 to be stamped "Waived" in R1's file when reviewing it. Administrator also confirmed the facility did not document the paintings that were reported as missing in January 2023 on the Resident Theft and Loss Record (LIC09060). Based on information obtained, the facility did not meet each requirement of its Theft and Loss Policy, per Health and Safety Code 1569.153. LPA finds the allegation to be SUBSTANTIATED - a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C(2)... 9099C(2).. Allegation: Staff did not provide authorized representative copies of resident's record. Complaint alleges that R1's records were requested and not provided within (2) days as required. Resident’s representative s tated he did submit a written request for copies of R1's records in December 2022 and sent it certified mail, and 2 days later, he sent a second correspondence via certified mail, giving 30- day notice. RP stated the records request stated "All records related to (R1)" and has not received any records to date. Administrator stated on 1/20/23 that RP asked verbally only for records during a phone call. MR stated that she did not tell RP the request had to be in writing and stated that RP and another individual on the phone call said they would be calling the corporate office. While reviewing R1's file, on 5/4/23, LPA observed a letter from RP, dated 12/20/22, requesting a copy of R1's file, to include specific documents. The envelope was sent via certified mail and had been opened. LPA discussed the letter with Administrator who stated she had not previously seen the request but had seen the other envelope, also sent by certified mail, giving 30-day notice. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Based on information obtained, LPA finds (3) allegations to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D pages Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents. 9099A-C(1). Resident's charting notes, dated 12/30/22, reflect a conversation with responsible person and a Med-Care Manager that resident's doctor just ordered new changes to R1's Seroquel order but resident will not start the new order yet since she will be moving in 2 weeks. Charting notes entered on 1/2/23 (17:33) document that another pharmacy delivered Donepezil and Buspirone to the facility and also faxed an order to taper off Seroquel. Notes indicate that the Wellness Nurse spoke to R1's responsible person and "he stated he doesn't want resident to start the medications at this time or make any changes with her medications since (R1) is moving out soon". Notes say responsible person is unsure how the other pharmacy got the orders from R1's primary care physician since he hasn't approved to start the medications yet. LPA reviewed a new order for Seroquel, dated 1/1/23, to discontinue the previous order for Seroquel and to give the following medications: Donepezil 10 mg (1/2 tablet daily for 4 weeks, then 1 tablet daily); Buspirone 5 mg- take 1 tablet by mouth, 3 times/day Seroquel 25 mg- decrease to 25 mg daily for 5 days then discontinue order . Order was signed by resident's nurse practitioner on 1/3/23 and faxed to the facility on 1/3/23 (1051). MAR records for January 2023 show that R1 was administered Buspirone and Donepezil through 1/6/23, morning dosage. MAR shows Seroquel was administered, twice daily, under the prior order on 1/1/23 - 1/2/23 and for the morning dosage on 1/3/23. A second dosage of Seroquel 25 mg was administered on 1/3/23 and on 1/4/23, the dosage was dropped to once daily. MAR shows the new order for Seroquel 25, once daily, was administered starting on 1/4/23 through 1/5/23. Resident moved out on 1/6/23. Based on documentation reviewed, the facility followed the physician's orders and administered medications as prescribed by the doctor . Resident was taken to the emergency room on 1/6/23 and was hospitalized until 1/8/23 for complaints of abdominal pain. Hospital medical records say resident was treated for colitis. It cannot be determined that because the facility followed physician orders with regard to the medication Seroquel, that resident was hospitalized. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. cont on 9099A-C(2).... 9099A-C(2).. Allegation: Staff overcharged resident while in care. Complaint alleges that following the first elopement, resident's (R1) responsible person was informed that R1, would require a full-time, 24/7 caregiver to watch over her, but the facility did not inform him that he would be responsible for paying the sitter. On/around 12/16/22, resident/resident's responsible person was issued a bill for for the private sitter from 8/31/22 to 12/16/22. Resident’s representative stated he was not told by the facility that he or resident would have to pay for the 1:1 supervision and and assumed it was included in the basic rent charge resident was paying. Responsible person asserted that he told the facility Administrator, he "refused to pay for 1:1 after the first AWOL" at the end of August 2022. Responsible person stated he didn't know how much the 1:1 supervision cost until December, on 12/16/22, when he received a bill, at which time he gave R1's 30-day notice.. RP stated he was not aware he was being charged for 1:1 until December when he received a bill. Interviews with multiple staff managers, including the Administrator, Business Office Director, Assisted Living Coordinator and Memory Care Coordinator, confirmed that R1's responsible person was told that he would need to pay for resident's 1:1 care needed to prevent her from eloping from the facility again. Narrative charting notes, on 8/28/22 and 8/31/22, document conversations and phone calls attempts with responsible person to discuss responsible person obtaining a 1:1 care giver, 24/7 for resident. Specifically, notes entered on 8/31/22 by Assisted Living Coordinator, Elaina, that the facility is "waiting on 1:1 being set up by RP (responsible person)". Ombudsman stated in an email to LPA that responsible person was told he would have to pay for the 1:1 supervision. Administrator stated there were initial discussions with R1's responsible person about the cost of a 1:1 caregiver, 24/7, but when follow up attempts were made by phone to discuss the discussion, the phone call would "always drop" with resident's responsible person stating he "didn't know what happened'". Administrator stated resident's responsible person has a "solid ballpark idea" of the cost a 1:1 caregiver, 24/7, would cost him. The Administrator stated the facility "stepped in because the responsible person was not following through" in obtaining a caregiver. Administrator stated a 1:1 caregiver was found through a new agency they had recently started working with for registry staff. Both the Administrator and Business Office Director confirmed that when a new vendor is used, there are billing delays in the system. Billing statements provided by the facility, dated 8/31/22, 9/30/22, 10/31/22 and 11/30/22, only show each monthly charge for basic services, medication and additional charges based on the resident’s service level. The 1:1 companion care, billed starting on 8/31/22 through 11/5/22, was not charged until the statement dated 12/31/22. The following monthly statement, dated 1/31/23, list charges for companion care for the period 11/6/22-12/31/22. cont on 9099A-C(3)... 9099A-C(3).. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with Nicole James, Director of Sales. Administrator, Marianne Richardson, attended by phone since she had to leave the facility before LPA was finished. with today's report. Copy of report left at facility.