complaint·January 18, 2023

Review of resident 2’s (R2) medical records revealed R2 had a diagnosis of dementia and falls, had wandering behaviors, and required assistance with grooming, dressing, bathing, and incontinence care. Review of an incident report submitted to the Department revealed that in March 2020, R2 got up from their wheelchair and lost balance, fell, and sustained an injury. R2 was transferred to the hospital for treatment. Review of resident 3’s (R3) medical records revealed that R3 had a diagnosis of dementia, had wandering behaviors, and required assistance with incontinence needs. Interviews with caregivers revealed that staff knew that R3 had wandering behavior and would sometimes have incontinence accidents while wandering. Staff would attempt to redirect R3 to use the restroom but R3 would get agitated when redirected. Records review of all three residents’ needs and services plans revealed that staff were instructed to keep residents 1, 2, and 3, in common areas during the day to maximize staff supervision during the day. Interviews with staff revealed that staff tried to keep residents in memory care in common areas to remain under staff supervision and staff increased checks on residents that had been identified as fall risks. Staff would check on residents that required assistance with incontinence care and were fall risks every 2 hours. Staff on the overnight shift would assist residents with incontinence care needs at approximately 11pm and 4am. Review of the staffing schedule revealed that between two and four caregivers and one to two medication technicians were scheduled per shift in the memory care. Interviews revealed that memory care staff were able to contact staff assigned to the assisted living if they needed extra assistance. Interviews did not reveal that there were any issues with staffing and that the number of scheduled staff were able to meet the needs of residents, including R1, R2, and R3. The Department has investigated the above-mentioned allegations and based on interviews and record review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Executive Director Diane Domingo, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.