complaint·February 29, 2024

A resident records review revealed R1 was admitted to the assisted living unit of the facility on October 19, 2019, with a diagnosis of Chronic Kidney Disease, Hypertension, AFIB, and Type II Diabetes. A review of resident records dated May 18, 2022, revealed R1 was showing symptoms of confusion, disorientation and wandering behaviors. On July 7, 2022, R1 was transferred from assisted living to the memory care unit of the facility. Staff interviews revealed R1 kept to themselves, and mainly stayed in their room. Staff interviews and a resident records review revealed R2 was admitted to the facility on August 17, 2020, with a primary diagnosis of Alzheimer’s disease, but no signs of aggressive behavior. An interview with Staff 1 (S1) revealed R2 was non-verbal and had a routine of walking in circles around the hall and a tendency to wander into other resident’s rooms. R2 would not show signs of agitation before they became aggressive and assault the caregivers and R2 had only physically assaulted staff, never a resident. The interview with S1 also revealed Outside Source 1 (OS1) hired a Private Caregiver (PC), however the PC opted to be reassigned due to R2’s aggression. An interview with Staff 2 (S2) revealed R2 was difficult to redirect because they would become angry and mean, and on occasion would spit on staff and other residents, although S2 was surprised by R2’s extreme violent behavior against R1 during the current incident. An interview conducted with Staff 3 (S3) revealed when R2 was first admitted they were pleasant but soon had a mental decline and was extremely emotionally unbalanced. S3 corroborated that R2 was a wanderer and had a tendency to wander into other resident’s rooms. A facility records review revealed, in contrast to staff statements, on November 20, 2020, R2 physically assaulted another resident in care and on December 20, 2020, a resident records review revealed R1 was assessed as in need of a Personal Care Attendant (the amount of time was not unspecified) due to their behaviors, and on May 5, 2022, approximately three (3) months prior to the incident under investigation, R2 was assessed as in need of a Personal Care Attendant every day for four (4) times a day. Interviews conducted with the Executive Director (ED) and S3 revealed R2’s Primary Care Physician (PCP) was adjusting their medications to address these behaviors prior to the incident. [CONTINUED ON 9099C] The interview with S3 also revealed on the day of the incident there were four (4) staff working in the memory care unit that housed approximately 28 to 30 residents, and R2 did not have a Personal Attendant or Private Caregiver. An interview with Staff 4 (S4) revealed, on the day of the incident, at approximately 7:00 p.m. they had checked on R1, and they were resting in bed conversing with a visitor. S4 also revealed checking on R2 at approximately 8:00 p.m. and could not locate R2 and asked a staff member regarding R2’s whereabouts and the caregiver pointed across the unit where R2 was observed walking down the hall towards R1’s room, S4 didn’t think anything of it because it was R2’s normal daily routine to walk the unit halls. Approximately 10 minutes later, Staff 5 (S5) came running down the hall towards S4 stating R2 had been injured and R1 was in their room. S4 and S3 ran to R1’s room and found R1 in their bed covered in blood and S4 immediately called 911 and began attending to R1’s injuries, while S5 escorted R2 out of the room. S4 revealed they asked R1 what happened, and they said they walked out of their bathroom and saw R2 was in their room sitting in their recliner. R1 asked R2 why they were in their room and told them to leave. R1 revealed after telling R2 to leave they began attacking them, and when R2 ceased the attack they sat back down in the recliner and R1 called the front desk receptionist for help from their phone, although memory care staff already knew by the time the receptionist tried to notify them Staff interviews revealed both residents were transported to the hospital. An outside source records review revealed R1 had dark blue Ecchymosis (contusions) on the right side of their face, and Ecchymosis and skin tears to their left side of their face, upper chest, bilateral upper and lower arm, and right anterior thigh, requiring wound care. R1’s injuries were caused by scratching and hitting during the assault by R2. R1’s injuries were treated and bandaged and R1 was discharged back to the facility the following day. An interview conducted with the ED revealed R2 remained at the hospital in restraints due to their agitation and was diagnosed with a Urinary Tract Infection (UTI). Upon discharge R2 was relocated to another facility. [See LIC 811 for confidential names] Based on evidence obtained, the allegation is substantiated because the preponderance of the evidence standard has been met. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D. An exit interview was conducted with ED Garcia and a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) was provided. ED signature below confirms receipt of the documents. The ED revealed being in communication with R2’s POA regarding what was best for R2. An Outside Source 1 (OS1) record review revealed OS1 had been misinformed and recanted that the ED ever said R2 could not return to the facility upon discharge. An additional outside source records review revealed a meeting with the facility staff and outside sources determined R2 needed a higher level of care. Based on staff and outside source interviews, as well as an outside source records reviews, the above allegation was determined to be unsubstantiated. An unsubstantiated finding means although the allegation could be valid the preponderance of evidence standard was not met. An exit interview was conducted with ED Garcia. A copy of this report and Licensee/Appeals Rights (9058 01/16) will be provided to ED Garcia at the conclusion of the visit. Signature below confirms receipt of the documents.