Incident investigation·February 12, 2025

On February 12, 2025, at 11:30 AM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Case Management – Incident visit regarding (2) incidents that occurred on 02/03/2025. Upon arrival, the LPA was greeted by the Assistant Administrator (AAD), Beth Shirley. The LPA disclosed the purpose of the visit. For incident #1, which occurred on 02/03/2025, resident (R1) eloped from the facility around 10:56 AM and was later found by a staff member at 12:05 PM, about 0.5 miles away from the facility. AAD stated that R1’s spouse talked to the nurse in the AL to took R1 to an event in the Independent Living Auditorium. R1 was sitting in the back of the Auditorium while the spouse was sitting in the front. R1 eloped from the auditorium, and the front desk receptionist was notified via the Roam Alert system that Assisted Living resident R1 had exited the building on their own. The receptionist notified the nursing staff and the Administrator. At 11:01 AM, the Administrator notified all managers via radio. Multiple staff members were sent out on foot and by car to look for R1. Searchers were provided with a picture of what R1 was wearing that day. At 11:35 Am, 911 was notified of R1’s elopement and began assisting in the search. Two Palo Alto police officers arrived at the building around 11:38 AM to assist. At 12:05 PM, R1 was found by a staff member about 0.5 miles away from the building. A staff member offered R1 a ride back to the community and they arrived at 12:14 PM. R1 was tired but was in good spirits. For incident #2, which occurred on 02/03/2025, resident (R1) eloped from the facility through stairwell exit around 05:38 PM and was later found by a staff member at 05:58 PM, walking about a block from the facility. AAD stated that the nurse on duty responded to an alert from Roam Alert system for Assisted Living resident R1. The nurse immediately checked the area around the alarm but was unable to locate R1. At 5:45 PM, the front desk was notified of the elopement. Staff were sent out to search the area around the building. At 5:58 PM, R1 was found walking less than a block from the building. R1 stated they were just going out for a walk. R1 was tired but was in good spirits upon their return to the community. Continued on LIC809-C LPA reviewed R1’s Physician’s Order Summary Report dated 11/18/2024, R1 has a primary diagnosis of Dementia, is ambulatory, and is deemed unable to leave the facility unaccompanied. The facility staff did not ensure that R1 didn’t leave the facility unaccompanied. Based on the review of R1’s Service Plan Report, on 12/15/2024, R1 attempted to elope via stairs to the basement. A deficiency was cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the Assistant Administrator. A copy of this report and appeal rights were discussed and left with the Assistant Administrator, Beth Shirley, whose signature on this form confirms receipt of these documents.