Incident investigation·March 9, 2023

At approximately 11:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management – Incidents visit and met with Executive Director/Administrator, Shannon Brown, and Charge Nurse, Melanie Fenn. The purpose of the visit is to follow up on incident reports that were self-reported to Community Care Licensing (CCL). Incident Report #1/Death Report: CCL received an incident report from the facility on 1/10/2023. The incident occurred on 1/9/2023. The report stated that Resident 1 (R1) was found outside in the bushes by another resident. The resident notified staff who notified Emergency Personnel. R1 was transported to the hospital. Facility made appropriate notifications per regulation. On 2/7/2023, CCL received a death report for R1. LPA, Executive Director, and Charge Nurse discussed R1. R1 resided in the Independent Living area of the facility. They were ambulatory with an assisted walking device and paid for a private caregiver. Facility has been in contact with the Marin Coroner regarding R1. Incident Report #2: CCL received an incident report from the facility on 1/27/2023. The incident occurred on 1/27/2023. The report stated that Resident 2 (R2) was observed by staff trying to get out of bed. R2 was observed to have a skin tear on their leg. Staff applied first aid and monitored R2 appropriately. Facility made appropriate notifications per regulation. LPA, Executive Director, and Charge Nurse discussed R2. R2 has a history of skin tears and was observed to have a change of condition and increased care needs. As of today, 3/9/2023, R2 has transitioned out of the facility’s Assisted Living and now resides in the facility’s Memory Care. Incident Report #3/SOC-341: CCL received an incident report from the facility on 2/14/2023. The incident occurred on 2/14/2023. Continued on LIC809C Continued from LIC809 The report stated that the Facility was informed by Resident 3 (R3’s) Responsible Party of potential financial abuse occurring between R3 and their private caregiver. Facility made appropriate notifications per regulation. LPA, Executive Director, and Charge Nurse discussed R3. Facility has been in contact with R3’s Responsible Party and Law Enforcement. Until the investigation is complete, the private caregiver has been suspended from being at the facility. Per conversation with the Executive Director and Charge Nurse, R3’s responsible party reviewed R3’s finances and made appropriate changes. The police investigation regarding the incident is still pending. No Deficiencies Cited during visit.