Incident investigation·February 24, 2025

At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an SOC341, Report of suspected elderly/dependant adult abuse form, a report of an elopement and a report of a medication error. LPA met with Environmental Director Jeramie Wager, toured the building and reviewed records. Incident 1: The SOC341 form was submitted by the Executive Director on 02/18/2025. On 02/17/2025, Residents, R1, family arrived to visit and observed R1 had not been repositioned or assisted out of bed. The family brought this to the attention of staff, S1, who stated they would not assist resident. Family informed the medication technician, who in turn reported this to the Executive Director. S1 was placed on suspension pending an investigation and retraining was done with all staff on Abuse and Neglect. LPA provided Declaration forms to staff witnesses. Incident 2: The facility submitted an unusual incident report on 11/25/2024 regarding an elopement that occurred on 11/22/2024. At approximately 11:45AM, while residents were gathering for lunch, staff could not locate Resident, R2. Staff searched the building to no avail and law enforcement was notified and a photo was provided. Management drove around the local area to search for R2. At approximately 12:43PM, Law Enforcement notified facility R2 had been located safe and unharmed, approximately 1 mile from the facility. Care plan was updated and resident was moved to a more secure location. Retraining on Elopement, Hospice, Tone and Call lights was completed with staff on 11/22/2024. Incident 3: The facility submitted an unusual incident report on 12/23/2024 regarding a medication error. On 12/09/2024, medication technician made an error in giving Resident, R3 the wrong dose of medication. Medication technician informed the facility nurse of the error. Resident did not have any adverse effects. Changes were made to the medication procedures to ensure medication errors do not continue. LPA requested the following documents and are to be submitted by 03/07/2025: -Documents regarding investigation for S1 refusing to assist resident. -Copy of staff file for S1, including training record. -Written Declaration forms from all staff witnesses. Continued on LIC809-C... Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Jeramie Wager and Appeal rights were given.