complaint·January 25, 2024

in the facility's Assisted Living unit. Initial documents sent to LPA included a medical assessment dated 10/24/2022 and indicated R1 is able to leave the facility unassisted, although R1 was marked with a diagnosis of dementia and being non-ambulatory and unable to evacuate without assistance. LPA interviewed management staff, who indicated this is R1's most recent assessment and that faxes to R1's physician to request a new medical assessment went unanswered. However, during today's visit, LPA reviewed R1's medical assessment dated 10/24/2023 which indicates that R1 has a diagnosis of dementia and cannot leave the facility unassisted. Care assessment dated 10/21/2023 and filled out by Aasta facility staff indicates R1 requires "some supervision in the home and needs attendance when outside the home or tends to wander". Interviews revealed that staff were aware R1 tends to wander, had attempted to leave the facility previously, and due to these behaviors R1 was on status checks every 15 minutes throughout the day and night. On the day of the incident, staff had seen R1 around 04:30AM in the hallway. At approximately 05:30AM, the facility received a phone call from paramedics asking about R1, who had been found in the community. Management interviewed indicated that when the phone call was received the facility staff were unaware that R1 had left the facility. Additionally, interviews also revealed that on the day and time R1 left the facility, there was 1 (one) caregiving staff working in Memory Care, and one Med Tech/caregiver working in Assisted Living. An additional Memory Care caregiver arrived at the facility at 05:30AM, however, during the overnight shift there were only 2 (two) facility staff present for 55 residents residing in the facility. Interview revealed it is unclear how R1 exited the building, R1 was found approximately 1 mile from the facility and staff were unaware of R1's whereabouts at the time emergency responders inquired. Based on interview and record review, there is sufficient evidence to support the allegation, therefore, the allegation that "staff neglect resulted in a resident leaving the facility unassisted" is deemed SUBSTANTIATED at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.