Complaint·December 30, 2021

On 08/02/21 at 4:35 p.m., LPA Sager conducted an interview with Administrator; on 08/03/21 from 1:22 p.m. to 4:45 pm., conducted interviews with Memory Care Director, Witness #2 (W2), and Witness #3 (W3); on 08/04/21 at 11:40 a.m., conducted an interview with Memory Care Charge Nurse. On 12/01/20, Memory Care Resident #1 (R1) and Resident #2 (R2) were involved in a physical altercation where R1 bit the hand of R2. Paramedics were called and R1 and R2 were taken to the Goleta Valley Cottage Hospital Emergency Room for evaluation. R2 was treated for human bite wounds to both hands. The hospital refused to place R1 on a Psychiatric hold. R1’s Power of Attorney (POA) was called to pick up R1. Upon arrival back to the facility, the POA was informed he would need to provide a one-on-one caregiver for R1. The POA agreed that he would be the one-on-one caregiver for R1 and took R1 to the Independent Living apartment at Maravilla. The POA contacted the Primary Care Physician who recommended hospice placement. On 12/02/20, R1 was assessed and admitted to hospice with a recommendation for a 5-day respite for medication management of R1’s aggressive behavior. POA agreed as he was not able to continue to be a one-on-one caregiver for R1 as was needed due to the aggressive behaviors. Per the Administrator, the POA was informed of the need for a one-on-one caregiver, initially agreed to be the one-on-one caregiver, then refused and said he could not afford to pay for a one-on-one caregiver. R1 continued to stay with the POA until 12/04/20 when the POA moved R1 out of the facility. R1 had previously lived in an Independent Living apartment at Maravilla with the POA. On 11/17/20, a pre-appraisal for R1 was completed by the POA and Memory Care Director, which did not indicate any aggression or behavioral issues. R1 transferred to the Memory Care unit of Maravilla on 11/17/20. Progress notes reviewed found that from 11/19/20 to 12/01/20, R1 had numerous incidents of increased confusion, wandering, agitation, yelling, medication refusal and aggressive behaviors. A Care Plan was completed on 11/17/20 noted that the resident had a current or history of behavior issues and needed hourly checks. Information obtained through interviews found that the POA was notified that R1 would need a one-on-one caregiver and that the POA agreed and wanted to oversee R1. Other interviews found that the POA was under the impression they would be the one-on-one caregiver only overnight. W3 stated that the POA informed W3 that “R1 was asked to exit the memory care”. W3 stated R1 was initially placed on hospice on 12/02/20 for a 5-day respite for medication management in order to give the POA respite from the one-on-one caregiving. The respite was extended and R1 remains on hospice. Information obtained from the Administrator found that R1’s behavior could not be managed in the memory care without a one on one caregiver while medications were being adjusted. Administrator states R1 was not evicted, she did not issue an eviction notice due to on 12/03/20 the POA informed her that R1 would be moving out of the facility. LPA Sager reviewed pertinent documents relevant to the allegations. LPA verified the one-on-one care clause in the Residence and Care Agreement which states: …”if it is determined that it is necessary to provide you with one-on-one care in order to protect your health and safety or the health and safety of others, we may provide or arrange for such care at our discretion and the charge for such one-on-one care, as set forth on Part C, Number 1, will apply immediately.” Based on the information obtained during the course of the investigation, LPA Sager determined there is not a sufficient amount of evidence to support the above allegations. The above allegations are deemed Unsubstantiated. Exit interview conducted and a copy of report given to Administrator.