complaint·October 5, 2023

It is alleged that resident wandered away from the facility due to staff neglect. LPA observed that R1 resides in the facility’s Memory Care Unit. The Memory Care Unit is a restricted unit in which staff need a key to enter and leave. A key is also required to use the elevator on the unit. During staff interviews, it was discovered that the memory care unit has an adequate amount of staff to care for the number of residents in care. Staff report that R1 did leave the memory care unit floor. R1 waited by the elevator, standing along side family members leaving the floor. The family didn’t know R1 was a resident of the memory care unit and allowed R1 to enter the elevator and leave floor. By all staff accounts, R1 did not leave the facility. R1 wandered around the first floor, never leaving the facility grounds. LPA unable to gather any information from R1 or family of R1. It is alleged that staff do not provide resident with daily activities. During LPA’s walkthrough of the facility, LPA observed a Large Print Activities Calendar posted in the hallway of the memory care unit. Accessible to all residents to read and join an activity. LPA also observed the dining room with different activity materials for crafting. Across from the dining room is an Activity Room with adequate seating. Staff report the room is used for group activities such as exercising or watching television. Resident are free to go in and out of the room as they please. This room included adequate seating as well as board and card games. LPA received a copy of the Memory Care Unit’s Activities Calendar which was consistent with observations. Staff interviews revealed that staff take turns throughout the day to lead activities. Staff encourage residents to participate, but participation is not mandatory. Staff report R1 may start an activity but may get distracted get up and leave. Staff allow residents to come and go to avoid aggressive or combative behaviors. It is alleged that staff do not provide accurate information needed to ensure resident is receiving appropriate care. Staff interviews revealed that R1 was taken to the hospital on two occasions. The first occasion was to address R1 injury. On the second occasion, R1’s daughter transported R1 to the hospital. A review of medical records and incident reports reflect that this occurred. Staff report that R1’s daughter was contacted to be notified of R1’s condition and current status but received no answer or returned call. On the second occasion, R1’s daughter was present during the hospital visit. Records also reflect ongoing communication between facility staff, R1’s daughter and Innovate staff. Innovage staff and R1’s daughter worked together to find better suited housing for R1 and closer to R1’s daughter. R1 officially moved out of the facility on 8/9/23. LPA was unable to reach R1’s daughter to obtain any other information or account of what occurred. Based on the information above, these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with facility representative and a copy of this report was provided.