Merisol Care Home

Allegation investigated: Staff failed to provide supervision resulting to resident wandering from facility resulting in death

On this day at around 2:30 pm, Licensing Program Analyst (LPA) arrived unannounced to deliver finding on the above allegation. LPA met with Soledad Bacani. LPA explained to Bacani the purpose of the visit. During the course of investigation, LPA conducted interviews, gathered copy of R1 death certificate, record reviews, and copy of Union City Police report dated 12/7/2023. Based on interviews conducted with staff, R1 was confused and had wandering behavior. Staff interviewed are aware that R1 had Dementia. Staff interviewed confirmed with LPA that R1 would walk around the facility looking for exits, saying, “I want to go home.” Staff are aware about R1’s elopement incident from a Memory Care unit in another facility prior to placement to this facility. continuation on Lic 9099C Substantiated On 12/7/2023, R1 eloped from the facility around 0930 hours. A review of Union City Police report indicates that the staff told police R1 possibly exited the facility through dining area sliding door. The police said that there were sensors on all of the doors that would ring when opened. However, the sensor was turned off on the sliding door in the dining area, and the backyard gate was open. R1 was found deceased by the railroad tracks. R1’s date of death as indicated in the death certificate is listed as “December 7, 2023 unknown hours.” The death certificate indicates “blunt injuries” as the cause of death, place of injury is “railroad track ballast in Union City” and description how injury occurred is “pedestrian struck by train.” R1’s 2023 Physician’s Report (PR) indicates R1 has Alzheimer’s Disease, confused and has wandering and sundowning behaviors with able to leave facility unassisted listed as “yes.” However, R1's 2022 Physician's Report (PR) from same treating physician indicates same diagnosis and behavior with able to leave facility unassisted as “no.” On 5/2/2024, LPA interviewed R1’s doctor regarding the two PRs. R1’s doctor stated that “….but considering R1 had dementia, R1 should not leave the facility unassisted.” Based on interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Sec 87705(b)(2) is being cited on the attached LIC 9099D. A Non Compliance Conference (NCC) is scheduled for August 15, 2024 to discuss plans of correction. Civil penalty determination related to serious bodily injury is pending. A copy of this report was provided to Bacani and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Aug 9, 2024 · control 15-AS-20231218143948

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Aug 15, 2024

87705(b)(2) Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: Based on interviews and record reviews conducted, R1 who has Alzheimer’s/Dementia, confused, disoriented and has sundowning behavior exited the facility without staff knowledge, got struck by a train and died on 12/7/2023.the state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: Plans of Correction will be addressed in the NCC on 8/15/2024. Civil penalty determination related to serious bodily injury is pending.

Type of visit: Case Management - Other

On this day, LPA Luisa Fontanilla conducted a case management visit related to complaint #15-AS-20231218143948 and met with Soledad Bacani, Administrator. LPA explained to Bacani the purpose of the visit. During the course of investigation, staff interviewed were aware about R1’s confusion and exit-seeking behavior. Staff interviewed state R1 would walk around the facility looking for exits saying, “I want to go home.” Staff were also aware about R1’s elopement incident from a Memory Care unit in another facility prior to placement to this facility. Despite awareness and observing R1’s wandering behavior, R1 was able to leave the facility without staff knowledge on 12/7/2023. R1 was found deceased by the railroad tracks. Deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D). A copy of this report was provided to the Administrator and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Aug 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 15, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such... This requirement is not met as evidenced by: The facility did not provide appropriate assistance to R1 to ensure safety despite observing R1’s wandering behavior. R1 was able to leave the facility without staff knowledge and was found deceased by the railroad tracks.the state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: Plans of correction (POCs) will be addressed in the NCC on 8/15/2024.

Type of visit: Required - 1 Year

On this day at around 10:20 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with staff Milagros Bumatay. LPA explained to Bumatay the purpose of the visit. The Administrator arrived at around 11 am. During the visit, LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, dining area, kitchen, garage and backyard. Hot water measured at 111 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. Ample supply of linen, warm blankets and towels were observed. First aid kit was observed complete. LPA observed a fire extinguisher that appeared full but did not have a tag or proof of purchase. The last fire and earthquake drill was conducted in November 2023. Smoke detectors and carbon monoxide were tested and observed functional. LPA reviewed three resident files and 4 staff files. All staff were observed fingerprint cleared and associated to the facility. LPA interviewed one resident and one staff. LPA reviewed medications and Medications Administration Record (MAR) with Administrator. The following deficiencies were observed: R1's exit door was observed blocked backyard was observed with grass more than 1 foot tall, construction equipment, luggage, right side passageway uneven pavement, garage door needed to be opened manually 2 knives observed unlocked in the kitchen carrots with mold in the garage R1 uses oxygen but fire department has not been notified missing No Smoking sign on R1's door continuation on Lic 809C Exit interview was conducted with the Administrator and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Mar 29, 2024

The state marks this report as 11 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On this day at around 9:45am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit and met with staff Teresita Collong. LPA explained to Collong the purpose of the visit. Administrator was informed over the telephone about the purpose of visit. Administrator authorized Collong to sign the report. LPA issued $250 civil penalty from 12/19/2023 visit for repeat violation. A copy of this report was provided to Collong. .the state’s words, verbatim · CDSS document, Dec 21, 2023

Type of visit: POC

On this day, LPA arrived unannounced to conduct POC visit from citation issued on 12/11/2023. LPA met with staff Teresita Collong. LPA observed facility has installed temporary video cameras in all four exits of the facility. Administrator is able to view/access all cameras by phone. A permanent video camera will be installed in the next few days per Administrator. The deficiency is cleared and a copy of this report was provided to Collong.the state’s words, verbatim · CDSS document, Dec 21, 2023

Type of visit: Case Management - Health Checks

On this day at around 10:30 am, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management-health checks in connection with complaint #15-AS-20231218143948. LPA met with Administrator Soledad Bacani. During the visit, LPA inspected the facility inside and out including but not limited to resident rooms, common areas, bathroom and backyard. Hot water measured at 115 degrees Fahrenheit. There was sufficient supply of perishable and non perishable foods. LPA checked alarms installed on each exit door and observed auditory device in Room 4 is not functional. One resident was observed sitting on the recliner in the living area watching TV/napping. The other two residents are in their respective rooms who both state they are doing okay. In the back and side yards, LPA observed construction materials such as planks of wood, chair, dresser, gravel and different tools. Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D). Exit interview was conducted and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Dec 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Dec 19, 2023

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: LPA observed auditory device installed in Room 4 is not functional which poses an immediate threat to the health and safety of clients under care.the state’s words, verbatim · CDSS document, Dec 19, 2023

Plan of correction: Administrator replaced the battery during visit.Deficiency is cleared

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Dec 29, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, wood planks, gravel, construction tools, dresser, chairs etc were observed in the side/back yards and kitchen windows with black mold which poses a potential risk to health and safety of clients under care.the state’s words, verbatim · CDSS document, Dec 19, 2023

Plan of correction: Administrator states will conduct general cleaning of the facility and will notify LPA. LPA will need to come back to verify completion.

Type of visit: Case Management - Incident

On this day at around 1:45 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management-incident visit and met with Administrator Soledad Bacani. LPA explained to Administrator the purpose of the visit. On 12/7/2023, Administrator left vm to LPA regarding Resident 2 (R2) missing from the facility. On 12/11/23, LPA made a follow up with Administrator. Administrator informed LPA that Resident 2 (R2) who had Alzheimer's Disease left the facility on 12/7/23 without staff knowledge. Administrator and staff tried to find R2 but failed. Administrator states she informed R2's family and Union City Police Department. And on 12/10/23, Administrator states R2's husband informed staff 1 (S1) that R2 passed away on 12/8/23. During the visit, LPA obtained the following records for Resident 1 (R1): Medication Administration Record (MAR) Physician's Report Admission Agreement Appraisal Needs and Services Plan Death Report Incident Report The deficiency is cited (refer to Lic 809D) from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview was conducted with Soledad. Appeal Rights was provided.the state’s words, verbatim · CDSS document, Dec 11, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Dec 15, 2023

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirementt is not met as evidenced by: R2 who has Alzheimer's Disease left the facility without staff knowledge on 12/7. Administrator & staff tried to find R2 but failed. The incident was reported to the police department and R2's family. On 12/10/23, R2's husband notified facility that R2 died on 12/8.the state’s words, verbatim · CDSS document, Dec 11, 2023

Plan of correction: Administrator will install Ring video camera on all exits and submit proof to CCL. Safety check every hour during the day; every 2 hours at night pending installation of ring camera. Once installed, every 4 hrs at night; hourly during the day safety check. A Non Compliance Conference will be scheduled to address issues.

Type of visit: Case Management - Incident

At around 10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management visit. LPA was met by staff Milagros Bumatay and informed the purpose of the visit. Administrator arrived at the facility at around 10:45am . On 9/15/2023, facility self reported an incident when Resident 1 (R1) with Dementia and is not able to leave the facility unassisted left the facility without staff knowledge. R1 was found by a concerned citizen, was brought to the nearby Fire station. R1 was then sent to Kaiser to get checked. R1 did not sustain any injury per Administrator. During the visit, S1 states that R1 exited through the side door. And that an alarm has been installed right after the incident. Administrator states R1 was given new medicine. Type A deficiency is cited per Title 22 California Code of Regulations (refer to Lic 809D). Exit interview was conducted with Administrator and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(h) · Plan of correction due date: Oct 20, 2023

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:Based on interview conducted, facility did not comply with section above in not having a working auditory device installed in R1's room resulting to R1 exiting the facility. R1 has dementia and is not allowed to leave facility unassisted.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator has installed an auditory device in R1's room which was observed operational during the visit. Also,LPA advised Administrator to come up with a plan regarding checking all auditory devices regularly. Deficiency is cleared.