complaint·December 6, 2023

All staff interviews revealed that on 11/26/2023 the facility experienced an unexpected power outage that triggered all of the exit doors. Staff immediately went to check the exit doors, conducted a headcount, and realized R1 was missing, and began to look for them. R1’s interview revealed that R1’s bedroom is near an exit door at the end of the hallway, they noticed the lights blinking and went out the exit door as they were trying to go to the bank and their house. Neighbors noticed R1 and called the police and R1 was taken to the hospital as they did not want to return to the facility. The facility failed to submit an unusual incident report (LIC624) to CCL and provided a copy of the incident report to the LPA during today’s visit. LIC 624 confirmed that R1 had walked out of the building and taken to the hospital for testing/evaluation after 911 was called by a neighbor. Based on the evidence this allegation is Substantiated at this time. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator Ken. On the allegation Staff locks resident in their room, it is the reporting party’s concern that the facility mistreats R1 and locks them in their room. To investigate the allegation, the LPA conducted interviews and toured the memory care unit. R1’s interview revealed that even though they would rather be somewhere else with their family, staff treats them “pretty darn good,” and they would select the facility to be in if it was necessary. At 11:26 a.m. the LPA observed R1’s bedroom to only have a lock from the inside of the bedroom. Staff interviews revealed that all bedrooms in memory care have keylocks and bedrooms generally stay unlocked unless requested to be locked by family members. If the doors are to remain locked, the resident must be able to walk and be able to unlock the door and a note on the door would be placed. Bedrooms are to be locked from the outside to prevent people from coming in. The LPA did not observe a note on R1’s door with the indication the door to be locked. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Staff locks resident in their room”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. On the allegation Staff does not ensure that resident is adequately fed, it is the reporting party’s concern that the facility does not feed resident appropriately. To investigate the allegation, the LPA conducted interviews and toured the memory care unit. R1’s interview revealed that even though they do not like the food being served at the facility, they are provided three (3) meals a day and they are not left hungry. At 11:09 a.m. the LPA observed enchiladas, rice, vegetables, smashed potatoes, and a dessert being served for lunch to the residents in care in the memory care unit. At 11:25 a.m. the LPA observed R1 eating their lunch. Staff interview revealed that the facility provides breakfast at 8:00 a.m., lunch at 11:00 a.m., dinner at 4:00 p.m. and snacks in between. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Staff does not ensure that resident is adequately fed”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview and report reviewed with Administrator Ken. A copy of the report and appeal rights were provided.