Incident investigation·September 29, 2022

Licensing Program Analyst (LPA) L. Cabrera conducted an unannounced Case Management visit. LPA met with Shelly Randel, Executive Director. Administrator was unavailable and designated Shelly Randel to meet with LPA. CCL Office received Unusual Incident/Injury Report (SIR) dated 07/06/2022. LPA follow-up regarding Resident (R1) not knowing how much Tylenol resident took. Facility immediately called the ambulance and R1 was transported to the Hospital. Facility is now administering all medications for R1. LPA requested new Physician’s Report for R1. CCL Office received Unusual Incident/Injury Report (SIR) dated 07/24/2022. LPA follow-up regarding R2 stage of wound on right hand. Per records reviewed, R2 has a skin tear only. CCL Office received Unusual Incident/Injury Report (SIR) dated 09/02/2022. LPA follow-up regarding R3 health and safety. No follow-up needed. CCL Office received Unusual Incident/Injury Report (SIR) dated 09/04/2022. On 09/07/2022, ED reported the incident to CCL. LPA follow-up regarding R4 absent without leave (AWOL). It was reported that on 09/04/2022, R4 went AWOL from the facility. On 08/27/2022, the egress door was out of service. ED implemented a plan for staff to conduct 15 minutes checks and document it. According to ED, all residents were accounted for at 9:45a.m. Two staff were assisting another resident while third staff was at lunch. ED reported there was no supervision in the common area. During the 10a.m. count, R4 was not accounted for. Facility conducted a search for R4. At 10:30a.m., Merced Police Department (MPD) was notified and MPD confirmed they had R4. ED reported R4 is a resident in Memory Care. R4 was transported to Mercy Hospital and returned on the same date. Per R4’s Physician’s Report dated 03/07/2021, R4 has mild cognitive impairment and is unable to leave facility unassisted. On 05/14/2021, R4 was admitted to Memory Care. A civil penalty is being cited, per California Code of Regulations, Title 22, Division 6, see attached 421IM. Exit interview conducted and Designated Representative was provided with the LIC809, LIC809-D and Appeal Rights.