complaint·May 15, 2024

(continued from LIC9099) signed back in at 3:07 p.m. R1 signed out on 1/17/2023 at 4:16 p.m. and never signed back in. The facility’s house rules indicate on rule number four that all residents must sign out and sign in upon return to the facility. A nurse came to the facility to meet with R1 on 2/2/2023, but R1 was not there. The receptionist told the nurse R1 had left that morning and she did not know when R1 would be returning. The nurse asked R1’s roommate about R1’s whereabouts and the roommate informed the nurse R1 had not returned to the facility for weeks. On 2/3/2023, the nurse conducted a medical eligibility search for R1 and discovered R1 had been reported deceased. The nurse then called the facility, spoke with the receptionist and asked to speak with R1. The receptionist told the nurse R1 was visiting their family member and did not know when R1 would return to the facility. The nurse then informed the receptionist that R1 had been reported deceased. The receptionist called the nurse back later and stated that R1 had signed out on 1/17/2023 and did not return to the facility. R1’s family stated R1 passed away on 1/19/2023 at a friend’s house. The receptionist explained that they had mistaken another resident for R1 when they told the nurse they had seen R1 on 2/2/2023. The nurse contacted R1’s family who informed the nurse R1 was deceased. R1 had gone to visit a friend on 1/17/2023 and passed away at the friend’s house on 1/19/2023. The facility had been unaware of R1’s whereabouts from 1/17/2023 until they received notification of R1’s death on 2/3/2023. The administrator at that time, Tillman Pink, submitted a death report on 2/7/2023 stating they were informed of R1’s 1/19/2023 death by R1’s family on 2/3/2023. Based on the information gathered from interviews and record review, the facility staff did not know the whereabouts of R1 for nearly three weeks. They did not review the sign-in/out sheet to follow-up on anyone who had not signed back in. Therefore, the allegation facility staff did not notice resident’s absence is deemed Substantiated at this time. The following deficiencies were observed (see LIC9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with administrator. A copy of this report with appeal rights provided to administrator.