complaint·October 16, 2024

On August 22, 2024, LPA Monter interviewed R1. R1 stated he/she doesn’t remember if his/her toilet in his/her bedroom was working. LPA interviewed R1’s Family Member (FM). FM stated it was possible that R1 was flushing too much toilet paper. FM stated every time an issue regarding the toilet would arise, staff S2 would fix it him/herself. On September 10, 2024, LPA Monter interviewed Residents R2-R5. 3 Out of 4 residents interviewed (R2, R4, R5) stated their toilet is functional and has not given them any issues. 1 Out of 4 residents interviewed (R3) stated he/she did an issue with his toilet, but it was fixed the same day by the maintenance director. LPA Monter interviewed facility Maintenance Director (MD). MD stated he/she has gotten a work order for R1’s toilet. MD stated he/she uses a snake “Augger” to unclog it. MD stated when he/she gets notified of an issue with a toilet, he/she will address it the same day as it’s a health and safety issue for the residents. MD stated he/she has several spares in storage that he/she can just replace if the actual toilet is damaged. On August 7, September 10, 2024, LPA made the following observations. LPA toured the following resident bedrooms: CE1, CE5, CE5, 5, CE9, 9, 20, 21, CE23, CE24, 24, 25, CE25, 29, 30. All resident toilets inspected were observed as clean and functional. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Neglect/lack of supervision resulted in resident eloping. On July 30, 2024, the Department received a complaint alleging Neglect/lack of supervision resulted in resident eloping. It has been alleged on June 17, 2024, Resident R1 had eloped. On August 5, 2024, the Department interviewed R1’s family member (FM). FM stated R1 never had a problem with wandering before moving to the facility. FM stated R1 has never wandered when he/she lived with him/her. FM stated wandering was not a concern before moving in. Page 2 Out of 5 On August 7, 2024, LPA Monter interviewed ADM and staff S1. ADM and S1 confirmed that on June 17, 2024, R1 had exited the assisted living building (Cedar) around 5am and had walked to the Monterey building. R1 then proceed to throw a flowerpot at the door of the Monterey building. S1 stated R1 then proceeded to knock on room 28’s door. (Independent living.) S1 stated R1 did not enter that resident’s bedroom. On August 22, 2024, LPA Monter interviewed resident R1. R1 stated regarding June 17, 2024, that he/she does not remember the details. R1 stated he/she went out for a short walk in the morning, but then couldn’t go inside the building. R1 stated he was frustrated that he could not enter the building, so he/she threw something. R1 stated he/she just wanted to walk by him/herself. R1 stated he/she thinks this is the first time this has happened but doesn’t remember. Based on a review of R1’s Physician Report dated April 21, 2024, R1 has a neurocognitive disorder. The Report also states R1 does not have wandering behavior. Based on a review of R1’s needs and services plan, dated May 9, 2024, R1 requires 2-hour status checks. Based on a review of R1’s 2-hour status checks log, R1 was last checked at 4am, on June 17, 2024. R1 was then checked again the same day at 6am. Based on a review of the facility’s sketch, the Monterey building is part of the facility grounds. Based on the totality of this investigation, R1 did exit the assisted living building and walk to the Monterey independent living building. Since the Monterey building is part of the facility grounds, R1 did not elope from the facility. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 3 Out of 5. Facility did not notify residents responsible party/CCLD regarding an elopement On July 30, 2024, the Department received a complaint alleging Facility did not notify residents responsible party/CCLD regarding an elopement. On July 30, 2024, the Department interviewed R1’s family Member (FM). FM stated was he/she was called and informed on June 17, 2024, at 5:30 am R1 left the assisted living building (Cedar) and had thrown a potted plant into the building door. On August 7 LPA Monter interviewed ADM and staff S1. ADM and S1 confirmed that on June 17, 2024, R1 left the assisted living building (Cedar) around 5am and had walked to the Monterey building. ADM and S1 stated R1 then proceed to throw a flowerpot at the door of the Monterey building then proceeded enter the building and knock on room 28’s door (Independent living.) S1 and ADM stated R1 did not enter that independent living resident’s bedroom. ADM stated he had a discussion with S1 and R1’s family member about R1’s change of condition. On August 22, 2024, LPA Monter interviewed resident R1. R1 stated on June 17, 2024, he/she went out that morning to take a short walk. R1 stated he/she was finished with the walk, he/she could not re-enter his/her building and became frustrated. R1 stated he/she threw something. R1 stated he/she just wanted to have a walk by him/herself. R1 stated he/she did not have an injury that day and states this is the first time something like this happened. On October 8, 2024, LPA Monter interviewed staff S1. S1 stated R1's family and physician was notified. S1 stated it was no injury to R1 or other residents because there was no other residents in area at the time of the incident. S1 stated this was a new behavior that was discussed with FM. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED , meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 4 Out of 5. Facility door alarm is in disrepair On July 30, 2024, the Department received a complaint alleging the facility door alarm is in disrepair. It has been alleged the door alarm in the assisted living building was in disrepair. On August 7, and September 10, 2024, LPA Monter interviewed staff S1-S6. 4 Out of 6 staff (S3-S6) interviewed stated the door alarm works and has not had any issue. 2 Out of 6 staff (S1, S2) stated the door alarm had an issue where the door alarm would be keeping ringing during the day, past 6am. S2 stated when the door open, it pages the NOC (Night) shift staff and notifies them that the door had been opened. S1 stated the issue was resolved the same day. On August 7, and September 10, 2024, LPA Monter interviewed residents R1-R5. R1 stated he/she doesn’t remember if the door alarm was functional. 4 Out of 5 residents (R2-R5) stated the door alarm works and stated there hasn’t been a time when it was not functional. On September 10, 2024, LPA Monter interviewed the Maintenance Director (MD). MD stated there was an issue with the door alarm. MD stated the if the door opens at 10pm-6am, then the NOC shift’s pager will buzz to notify them that the door had been opened. MD stated the issue was that the door alarm would stay on and keep buzzing even after 6am. MD stated the issue was resolved the same day. Based on interviews conducted, the door alarm in the assisted living unit was not in disrepair, rather it’s settings were not calibrated correctly. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 5 Out of 5. END OF REPORT On August 22, 2024, LPA Monter interviewed Resident R1’s Family Member. (FM). FM stated after the incident on June 17, 2024, FM stated he/she was informed by the ADM and S1 that R1 would require a higher level of care. FM stated he/she didn’t want R1 in memory care. FM stated he/she was told that R1 would require a 1 on 1. FM stated he/she was told that R1 will need to be moved as quickly as possible. LPA requested FM any documentation from the facility stating R1 was being evicted. FM did not provide LPA with any documentation. On October 16, 2024, LPA Monter interviewed staff S1.S1 stated he/she and the facility ADM were both there during the conversation with FM. S1 reiterated that the facility did not evict R1. S1 stated that FM told ADM and S1, after the conversation about R1's change of condition, that if he/she needs to give the facility a 30 day notice to vacate. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that R1 was evicted from the facility. Staff did not follow a licensed physician's order On July 30, 2024, the Department received a complaint alleging staff did not follow a licensed physicians order. It has been alleged R1’s medication 1 was not given. On August 5, 2024, resident R1’s Family Member (FM) stated, R1 was taken to the hospital to see his/her physician. FM stated R1’s physician gave 2 sample medications for R1 to use on May 23, 2024. FM stated he/she brought the medications to the facility and they informed her that they could not give R1 the inhaler since it was a sample even though FM had written a prescription. FM stated he/she administered R1’s medication him/herself, so there would be no delay in R1 receiving the prescription. On October 2, 2024, LPA Monter interviewed ADM. ADM stated the facility did not administer the medication because the medication did not contain the proper labeling requirements. ADM stated FM did not authorize the pharmacy to fulfill the prescription order. Page 2 Out of 3. On October 8, 2024, LPA Monter interviewed Staff S1. S1 stated the medication bottle FM brought did not have the state required labeling. S1 stated he/she was going to order the prescription but FM refused. S1 stated, FM only wanted to use the sample due to the cost of the medication. S1 stated FM told him/her that he/she would administer the medication and took the sample medication with him/her. Based on a review of R1’s needs and Services Plan, dated May 9, 2024, stated R1 receives assistance with self-administration of medications up to 2 times a day. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that R1 was evicted from the facility. Page 3 Out of 3. END OF REPORT.