Complaint Investigation Report

On the allegation " Staff do not prevent resident from entering other residents' rooms"; it is the concern of the reporting party (RP) that Resident 1 (R1) goes into other resident’s rooms and roams the halls at night. It was further reported that R1 needs more care than what staff can provide. To investigate the allegations the LPA conducted a file review and interviews. A review of R1’s charting notes from 10/01/2023 to 02/14/2024 revealed that R1 had been wondering into resident’s rooms and wondering the halls during the day and at night very confused on different occasions. Additionally, on 10/04/2023, it was charted that R1 tried to take shirts from another resident and when the resident told them no, R1 bit them. On 12/24/2023, it was charted that at approximately at 8:37 p.m. it was reported that R1 could not be found, and R1 was found at 10:55 p.m. Majority of the residents interviewed revealed that R1 has entered their room uninvited, with one of the residents stating that they have voiced concerns to management and another resident stating that they feared R1. Staff interviews revealed that based on R1’s behaviors and needs they believed R1 required a higher level of care, such as being place in the Memory Care unit. Interview conducted with current ED, Kailey Vanderwall during today's visit revealed that R1 has been placed in memory care as of 04/24/2024. Based on interview and record review, the allegation that " Staff do not prevent resident from entering other residents' rooms " is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D).

Exit interview conducted. A copy of the report and appeal rights provided.