Incident investigation·April 27, 2021

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management - Incident visit at the facility today to follow up on an incident pertaining to Resident #1 (R1). The LPA met with Executive Director Nancy Nelson and explained the reason for the visit. On 4/9/2021, the LPA received a call from the Executive Director, whom reported an elopement. On 4/8/2021 at approximately 7:20am, R1 was noted to be absent from their assisted living apartment. The facility contacted R1’s responsible party and local law enforcement. At 9:40am, R1 was found uphill outside of the community, approximately half a block away from the building. R1 was observed to have sustained scratches to their legs. Per interviews and records review, the length of time in which R1 was away from the community was between 2-3 hours. R1 was taken to the hospital and admitted for examination. R1 returned to the community on 4/13/2021. Prior to the on-site visit, the LPA obtained copies of R1’s physician’s report, R1's appraisal dated 3/1/2021, and the appraisal completed after the incident dated 4/16/2021. During today’s visit, the LPA spoke with the Executive Director, reviewed documents, and observed the location in which R1 was found. Based on interviews and records review, R1’s physician’s report dated 3/12/21 confirmed that R1 is not able to leave the facility unassisted. Interviews confirmed that although the community has twenty-four-hour concierge service, it is assumed that R1 left the facility through the front door, unbeknownst to staff. The facility is not equipped with Wanderguard, yet there are alarms on the door to alert staff. Although the doors were secure at that time, it is assumed that R1 left the building when another staff person came on shift. Since the incident, R1 has been reassessed and is now residing in the secured Memory Care Unit. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued via email. Signatures were obtained.