Incident investigation·September 24, 2024

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an Incident Report received in our office on September 18, 2024. LPA was greeted and granted entry by the Concierge at 11AM. LPA met with Ashiman Gill, Administrator (AD) and LIbbie Retts, RN, MSN, CENP, Director of Health Services (DHS). The purpose of the visit is follow-up on an elopement by Resident #1 on September 16, 2024. LPA requested copies of the resident care plan, identification page and medical assessment since records are kept electronically. LPA also requested the staffing schedule for September 16, 2024. LPA noted there were three caregivers on the evening shift (2-10:30PM), one MedTech (10AM-6:30PM) and two charge nurses who overlap (7:30AM-4:00PM) and (2:30-11:00PM) based on facility staffing plan. A recent Care Conference was held on September 12, 2024 prior to the elopement. It is noted in the care plan that the resident is exit seeking but also engages in activities. At 4:45PM resident was not accounted for in the dining room and the elopement procedures were immediately implemented. Staff discovered resident within twenty-five minutes and redirected resident back to the community with no incident. Resident was assessed with no injuries and lab work was initiated to rule out other underlying causes. LPA interviewed resident prior to lunch and was engaged in a crossword puzzle with a 1:1 staff member. Family agreed with AD and DHS recommendations to have more staff rounds in the thirty minutes prior to dinner time. Staff were in-serviced regarding security and safety measures and expectations for the health and safety of the residents in the community. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Ashiman Gill, AD and Libbie Retts, DHS and a copy of the report was given at the time of the visit.