Complaint·December 2, 2021

According to Complainant, R1 was admitted into the assisted living side of the facility beginning of August 2020. The 3 rd week of August, R1 was able to leave the facility and did not notify facility staff. After the incident R1 was transferred to the memory care side to make sure there was more supervision for R1. R1 was able to leave the facility again without staff’s knowledge. Complainant had to call the facility to notify them that R1 had left the facility. Records review revealed, on 08/03/2020 an initial level of care assessment was completed by the facility. It was discovered, R1’s elopement history and concerns were reviewed by facility’s Resident Care Director (RCD). On 09/07/2020, a second level of care assessment was completed by the facility due to R1 being moved to Memory Care Unit. The level of care assessment states that R1 requires staff to escort up to 3 times daily and requires checks at regular interval. On 10/02/2020, a third level of care assessment was completed by the facility. Changes in the level of care assessment indicated an increase in R1’s required checks at frequent intervals. The Department interviewed and received statement from Resident Care Director (RCD), Allison. RCD was asked to elaborate on R1’s level of care assessment which states that R1 requires staff to escort up to 3 times daily. RCD stated R1 is being escorted to breakfast, lunch, and dinner. RCD was asked to elaborate requires checks at regular intervals. RCD stated, if resident was on status check then staff is to check on resident throughout the day and night. RCD was asked if staff is required to check on R1. RCD answered, yes. It was discovered that on 07/29/2020, R1 moved into the assisted living unit of the facility. On 09/05/2020, R1 was moved to memory care unit. The Department reviewed facility’s communication with R1’s Physician. On 10/03/2020, the facility notified R1's Physician that R1 had left the community on 10/02/2020 at 2 PM and was taken to his former residence by a good Samaritan. R1 was transported back to the community in good condition. No c/o pain or discomfort. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC9099D. Appeal rights provided to the facility. An exit interview was conducted with Debra Duval, Executive Director, and a copy of this report will be provided to the facility via email. CCL received an Unusual Incident/Injury Report from the facility indicating R1 was sent to Roseville ER due to a medical emergency. On 10/13/2020, staff found R1 significantly weaker and unable to get out of chair. R1 made complaints of dizziness, difficulty breathing, and difficulty seeing. Staff called 911 at 4:10 p.m. and remained with R1 until emergency response arrived at 4:20 p.m. R1’s Responsible Party (RP) was notified. According to the facility, R1 did not return to the community and was moved to a higher level of care facility. The facility conducted a total of three (3) Level of Care Assessments on R1. On 08/03/2020, R1’s Level of Care Assessment revealed R1 has moved into the Assisted Living Unit and does not require hospice services. On 09/07/2020 and 10/02/2020, another Level of Care Assessment was performed on R1. Documents revealed R1 moved out of the Assisted Living Unit to the Memory Care Unit. Changes in the Level of Care Assessment include the facility requiring staff to check on R1 at regular intervals due to elopement history. There is no indication on the Level of Care Assessment of change in health condition or require hospice services. The Department reviewed the facility’s communication with R1’s Physician on 10/13/2020. Documents revealed that the reason for communication was due to R1’s change in behavior and later that day was transferred to the hospital. R1 has been very confused for the last few days. R1 was complaining about shortness of breath, not able to get put of chair, has been having delayed response to questions, and when calling R1’s name. Facility reported to R1’s Physician that R1 is not able to do something that R1 was doing before. Facility asked for R1’s Physician’s advice. Physician responded back to the facility that R1’s responsible party was notified of change of condition and 911 was to be called. This agency has investigated the above listed allegations. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegations to be UNSUBSTANTIATED. An exit interview conducted, and a copy of the report was left at the facility.