Complaint Investigation Report

Allegation: Staff did not provide adequate supervision resulting in resident wandering away from facility.

To investigate this allegation, LPA conducted an interview with the Administrator and was informed that R1 had been living at this facility for three (3) years. Based on a Physician’s Report (dated on 06/26/24) R1 was able to leave the facility unassisted. Administrator also informed LPA that no major changes have been observed in R1’s mental condition. Facility entry door is always unlocked. Residents/staff may open the door from the inside, however, no one can get in from the outside before 8:00am or after 7:00pm. Interview with S1 revealed that, at approximately 7:30am, S1 conducted morning routine and visited R1’s room. S1 stated: “I didn’t see R1, so I assumed that R1 already went to the dining area for breakfast.” After discovering that R1 is not present at the dining area, S1 immediately paged all staff members for an assistance to search for R1. Interview with the Wellness Director confirmed the statement provided by S1 and LPA was informed that WD immediately contacted the Northridge Hospital to report and or obtain information. Hospital nursing station informed WD that around 7:30am, R1 was found by the facility and picked up by 911 Paramedics. As of 8:00am, R1 was admitted to the hospital and was receiving medical care for her injuries. LPA requested R1’s medical records on 01/24/25 and received it on 02/25/25. Review of R1’s medical records revealed that upon admission, R1 was heavily bruised all over his/her face, has a hematoma on his/her forehead and bruising around both yes and down the side of her neck. R1 was unable to recall what happened, stated that he/she may have gotten in a fight. Lastly, LPA conducted interviews with seven (7) residents and four (4) out of seven residents informed LPA that they may leave the facility unassisted, due to Assisted Living (Independent Living) at Brookdale. However, immediate assistance can also be provided by the staff upon residents’ request. All residents interviewed expressed no concerns regarding this allegation and informed LPA that staff is very well trained to provide extra attention, care and supervision to all residents. Based on interviews and record reviews R1 did not wander from the facility as R1 was independent and able to leave this facility as desired. Therefore, this allegation is deemed Unsubstantiated, at this time.

No deficiency cited during today's visit.

Exit interview conducted and copy of this report signed and delivered.