Incident investigation·October 21, 2021

This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Kathrina Chin to follow up on an incident reported to Community Care Licensing. LPA met with Kelly Conk, Executive Director and Amy Cole, Assisted Living Director and explained the purpose of today’s visit. LPA made a case management visit in order to address four incident reports dated 10/2/2021,10/18/2021, 10/19/2021, 10/20/2021. It was reported that resident 1 (R1) pulled a patio chair to the gate and climbed over the secured/alarmed courtyard gate and wandered away from the facility for approximately twenty minutes on October 2, 2021. A private duty was put in place for 72 hours and a care conference meeting. The responsible party made an appointment for a neurologist and his Primary Care Physician(PCP). PCP came to the facility on October 8, 2021 and R1's medications were adjusted. On October 18, 2021, resident set off the delayed egress courtyard door causing an alarm. Care staff approached the resident and the resident took off his belt, wrapped it around his hands and came toward the staff. The staff called the safety team who responded and contacted 911 emergency personnel. Staff were able to re-direct resident to his room. On October 19, 2021, resident broke off the window stopper and pushed the screen off the window. Staff was able to see the resident attempting to climb out the window and resident came back in to his room. A 1:1 staff from a private vendor provided 24 hour supervision. On October 20, 2021, a companion entered the resident's room and the resident punched the male companion on the face. The facility contacted 911 emergency personnel and the paramedics did not take the take the resident to the hospital. A Primary Care Physician(PCP) was contacted today, October 2021 and will be consulting with a psychiatrist. There are new medications orders for resident 1. Ms. Conk stated that facility will hold another care conference to discuss a possible placement to a higher level of care. Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.