complaint·May 6, 2024

Continued from LIC 9099 (page 1) Allegation: “Facility staff are not meeting resident’s basic care needs:” The complaint alleges that the facility staff are not meeting Resident #1 (R1)’s basic care needs, as R1 has been able to elope on the following dates: 06/05/2022, 06/07/2022, 06/29/2022, and 07/11/2022. R1’s physician’s report indicates that R1 has a diagnosis of dementia, can ambulate without the use of assistive devices, has wandering behavior and is unable to leave the facility unassisted. Following the first 2 (two) elopement incidents, R1 was given a Wanderguard bracelet and additional status checks were conducted on R1. However, interview revealed that the Wanderguard bracelet will only set off an auditory alarm if the resident exits from the Assisted Living common areas, not the secure Memory Care unit and R1 resided in the Memory Care unit. Additionally, following the second elopement, the facility had required that R1 have a private companion due to safety concerns and exit seeking behaviors. However, after noting that the private companion agitated R1 more, the facility allowed R1 to remain in the facility without a private companion. LPA conducted a case management visit and issued a citation related to R1’s elopements. On 06/09/2022, facility staff conducted a new needs and service assessment, which did not indicate the need for 1:1 supervision for R1, however did note R1’s exit seeking behavior. R1 then eloped a third time on 06/29/2022, which resulted in a Case Management visit and additional citation on 07/08/2022. A self-reported incident report was sent to CCL related to a 07/11/2022 incident which indicates that R1 “attempted elopement” on this date. However, care notes for R1 reviewed at the facility indicate R1 “eloped with another resident.” Interviews with staff present during the incident indicated that R1 was “found with another resident on the sidewalk outside Oakmont wandering toward the public sidewalk.” During the initial complaint visit, LPA Dulek and Regional Operations Specialist, along with Memory Care Director toured the facility. During the tour, Memory Care Director showed LPA an inconsistency with the door strike on the door R1 eloped through during all elopement incidents and all of R1’s additional elopement attempts. If the door was pushed on the door strike rather than pressing the exit bar, then the door would open without engaging the delayed egress nor would it sound an auditory alarm. Previous ED and Memory Care Director had discovered this immediately following R1’s elopement on 07/11/2022. However, during the initial complaint visit on 08/11/2022, the door strike had not been repaired. Further, in a conversation with R1’s family following the 07/11/2022 incident, management had indicated the facility cannot keep R1 safe. Based on interview, observation, and record review, there is sufficient evidence to support the allegation, therefore the allegation Continued on LIC 9099-C Continued from LIC 9099-C (page 2) that “facility staff are not meeting resident’s basic care needs” is deemed SUBSTANTIATED at this time. Allegation: “Illegal eviction:” It was alleged that Resident #1 (R1) was asked to be picked up from the facility following an elopement on 07/11/2022, then the facility management would not allow R1 to return to the facility without a private companion. Interview with R1’s family revealed that management had called and spoken with R1’s family members and informed them that the facility was unable to meet R1’s care needs following the 07/11/2022 elopement. The family was informed that R1 could return with a 24-hour private companion at a cost of $40/hour. Without a private companion R1 was unable to return to the facility. Staff interviewed confirmed the resident was offered the ability to return to the facility with a private companion. However, staff interviewed also confirmed that the previous attempt to have a 1:1 private companion with R1 had caused R1 additional stress and increased agitation; therefore the 1:1 care was almost immediately discontinued. Staff acknowledged that although they had offered this option to R1’s family, this was not a viable option due to the previous experience. R1’s assessments reviewed, and staff interviewed indicate that staff were aware that R1 was an elopement risk upon admit to the facility. Additionally, staff interviewed indicated that the previous ED and Memory Care Director had discovered the inconsistency with the door strike, which was what was allowing R1 to exit the facility unnoticed, yet this door was not repaired upon discovery. Staff acknowledged that had this door functioned properly, the delayed egress would have sounded an auditory alarm when R1 attempted to elope and staff could have responded appropriately, preventing elopement incidents. Interviews and record review revealed this was the only door R1 eloped or attempted to elope through. Interview with R1’s family revealed that R1 was moved out 2 (two) days after the elopement incident, as they were verbally told the facility could not keep R1 safe and they would continue to incur charges until R1’s belongings were removed. Record review revealed that no written notice was given to CCL nor to the family. Therefore, based on interview and record review, the allegation “illegal eviction” is deemed SUBSTANTIATED at this time. The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email, per ED Foerschner’s request. Continued from LIC 9099-A (page 5) Allegation: “Insufficient staffing:” The complaint alleges there is not enough staff at the facility in the Memory Care unit. LPA reviewed staff schedules and conducted staff interviews. At the time of the complaint allegation, there were 3 (three) care staff scheduled during the am shift, 3 (three) care staff during the pm shift and 2 (two) care staff during the NOC shift. Interviews revealed that when staff call out, either staff will stay and work a double shift or the facility will use agency staffing. Additional staffing during the day hours include the Memory Care Director, medication technician, and activity staff. As the complaint relates to morning/daytime staffing, LPA observed staff during this specific time period. During the LPA’s visits, LPA observed multiple staff throughout the Memory Care unit, as indicated in the staff schedule. At the time of the initial complaint visit, there were 17 residents in Memory Care. Staff interviewed indicated that there is sufficient staffing to meet the care needs of the residents. Based on interview and record review, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “insufficient staffing” is deemed UNSUBSTANTIATED at this time. Allegation: “due to lack of supervision, resident eloped from the facility:” The complaint alleges that the facility staff are not properly supervising R1, resulting in several elopements from the facility. Record review and interviews did confirm that R1 has had several elopements and attempted elopements from the facility through one specific door. Interviews revealed that on days R1’s family has visited R1 that their elopement attempts have increased and, on those days, staff keep a closer watch on R1 to prevent elopements. As identified above, the facility does have sufficient staff coverage in the Memory Care unit and activities are offered to all residents. Following R1’s fourth elopement from the facility, which included a second resident leaving the secure Memory Care unit with R1, ED and Memory Care Director conducted additional testing and observation of the door in which R1 has exited during every elopement. Interview revealed that there was an inconsistency in the door strike, which allowed R1 to exit without an auditory alarm sounding, thus indicating a maintenance/physical plant concern rather than lack of supervision. Record review revealed that although R1 did have wandering behavior, R1 did not require 1:1 supervision. Staff interviewed indicate that R1 was redirected when R1 was found wandering away from the common areas and towards R1’s preferred exit door. However, R1’s room was located in the hallway close to Report Continued on LIC 9099-C Continued from LIC 9099-C (page 6) the exit door and as R1 does not require 1:1 supervision, staff are not always present in that hallway. During all facility visits related to R1’s elopement, sufficient staffing was observed, and staff responded quickly to all auditory exit alarms. Based on interview, record review, and observation, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “due to lack of supervision, resident eloped from the facility is deemed UNSUBSTANTIATED at this time. Allegation: “Facility staff are not engaging resident in activities:” The complaint alleges that Resident #1 (R1) was not engaged in activities during the morning shift, causing R1 additional unwanted behaviors. During the investigation, LPA Dulek obtained and reviewed a copy of the facility’s Memory Care activity schedule, observed residents and staff engaged in activities, and interviewed activity staff, as well as care staff. Interviews revealed that R1 hesitated to engage in activities. Staff invited R1 to participate in all scheduled activities and escorted R1 to the activity areas, but R1 would just sit at the table and not engage. After some time, R1 would then leave the activity area and wander the secure Memory Care area. Care notes indicated staff kept bringing R1 back to activities. Review of activity schedule revealed the facility offers a minimum of 8 (eight) activities at various times throughout the day with the first activity beginning 09:30AM and the last offered beginning at 06:30PM. During various facility visits throughout the investigation, LPA observed many residents involved in the facility activities and facility staff assisting the residents in their activities. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that “facility staff are not engaging resident in activities” is deemed UNSUBSTANTIATED at this time. No citations issued related to the above complaint allegations. Exit interview conducted. A copy of the report was provided via email, per ED’s request.