Complaint·October 29, 2024

Continued from 9099... During investigation, LPA reviewed outside agency statement which reports that resident has history of being verbally and physically aggressive towards facility staff, a history of making false allegations, and that resident is noted to be an unreliable historian. So, 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, therefore the allegation is UNSUBSTANTIATED. Continued from 9099A... During investigation, LPA reviewed R1’s care plans. R1’s care plans indicate that the resident is independent and likes to go on walks and enjoys being outside. During investigation, Admin reported to LPA that she knows R1 likes to be outside and go on walks, it helps to de-escalate R1’s aggression, among other positive benefits. As a safety measure and precaution, Admin pro-actively purchased a GPS tracker for R1 to wear when going on walks so that if R1 is gone longer than 10 minutes, R1’s location can be quickly determined. Admin purchased this GPS with family of R1’s approval. During investigation, LPA reviewed the four [4] most recent physician’s reports and care plans for R1. Three [3] out of four [4] of the physician’s reports reviewed indicate that the resident can leave the facility unassisted, for short walks outside. However, the most recent physician’s report indicates a change in R1’s assessment of leaving the facility unassisted, the most recent physician’s report indicates that the resident cannot leave the facility unassisted. Admin advised LPA that Admin must have accidentally overlooked this change in the most recent physician’s report section that indicates that the resident cannot leave the facility unassisted. So, the caregiver allowed R1 to briefly be outside unsupervised, as the caregiver was not aware of the change in R1’s physician report. Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D