Complaint Investigation Report

but not limited to, Physician's Report (LIC 602), medication list, Assisted Living Waiver (ALW) assessment and Hospice documents. From 11:00 a.m. to 3:00 p.m., LPA Rios conducted interviews with eight (8) staff not including the administrator and seven (7) residents.

The investigation revealed the following:

Regarding the allegation, due to lack of supervision, resident eloped . It is alleged the facility did not provide adequate supervision, resulting in Resident #1 (R1) leaving the facility and being found wandering in the community. Interviews with two (2) out of seven (7) residents stated they have seen residents who should not leave unassisted attempt to walk out the front door, but staff had been able to redirect them back inside. Six (6) out of seven (7) residents stated there is a sign-in/sign-out log at reception. R1 was not interviewed as they were not at the facility at the time of the visit. R1 is in a skilled nursing facility (SNF) for higher level of care. Residents stated that they don’t consistently sign out or sign back in when returning from the community. Interviews with staff reported the staff are able to assist each other and redirect residents that may have been noted as not being able to leave the facility. Per the receptionist, R1 has left the facility unassisted previously and has returned. Staff also reported that residents are encouraged to sign out and sign in when leaving and returning to the facility. Interviews with nine (9) staff revealed that R1 appeared fine or no more confused than usual in the days leading up to the incident. According to staff interviews, R1 received their morning medication but was not found for their evening medication pass at approximately 3PM. The Administrator was notified, and at approximately 8:00 PM the facility was informed that R1 had been found wandering in the community and transported to the hospital. Staff denied any prior incidents of elopement involving R1. Review of R1’s Physician’s Report dated 01/25/2025 notes R1 may leave the facility unassisted and documents that R1 has some forgetfulness. Review of R1’s Individual Services Plan with start date 07/02/2024 and end date 01/02/2025 notes R1 requires reminders and redirection but does not exhibit wandering behaviors.

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 at this time.

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was provided to Nina Mercado.