Incident investigation·November 3, 2023

At approximately 8:40pm LPA Christi Coppo arrived unannounced to conduct a case management regarding Incident Report received on 10/24/2023. LPA met with Executive Director, Morgan Holien and requested resident's records to review. Per facility’s Incident Report: On 10/22/2023 at approximately 7:30am, the resident (R1) was returned to the facility by their son. The facility thinks that perhaps R1 left through their patio door. The patio door opens to the unsecured facility parking lot. The facility thinks that perhaps R1 walked over to a friend’s house and slept in their backyard. R1 woke up in the friend’s backyard on 10/23/2023 and then walked back to their son’s house. Facility thinks that R1 had experienced a fall at some point during their elopement because they had noticeable bruising on their head and a scraped area on their leg. Facility gave R1 a shower and dressed their scraped leg. Facility also put hourly resident checks in place when overnight caregiver or family is not present. At approximately 9:50am LPA met with Health and Wellness Director (HWD) Jody Livingston. HWD indicated that R1 moved into facility on 10/13/2023, not 09/30/2023 as reported on Incident Report indicated. Facility was advised by R1's son that R1 had a caregiver that will be with him 24 hours per day, one from 8:00am-8:00pm, and another from 8:00pm to 8:00am. Caregiver was placed by First Light Home Care (Director Maria Mann 707-501-9830). Per HWD, the family canceled the caregiver on 10/22/2023 but did not notify facility staff of cancelation. Per HWD, as a result of being informed that R1 had a caregiver, staff were not instructed to check on resident during the time frame of 8:00pm on 10/22/2023 to 7:30am on 10/23/2023. Therefore, no one at the facility realized the resident was gone until the resident's son brought the resident back to the facility at approximately 7:30am on 10/23/2023. At approximately 10:50am LPA reviewed R1’s LIC602 and observed the following: R1 has a diagnosis of Mild Cognitive Impairment with hypertension and coronary artery disease. R1 was not known to have wandering behavior or sundowning behavior, R1 is not able to leave the facility unassisted. Per HWD, on 10/24/2023 the resident's PCP came to facility to evaluate R1. Based upon evaluation, R1 had a medication added to address his Major Depressive Disorder. LPA reviewed e-Mar and confirmed addition of new medication. Per HWD, as of 10/24/2023, a private pay caregiver has resumed attending to R1 from 8:00pm-8:00am. Facility produced Hourly Status Check log indicating hourly staff check of R1, beginning 10/23/2023 at 9:00pm to address wandering behavior. At approximately 12:45pm LPA reviewed R1's updated Care Plan and confirmed that facility updated resident's Care Plan to monitor resident for wandering and/or elopement behavior. Per LPA interview with HWD, hourly monitoring of R1 will take place 4 times per AM and PM shift and 2 times per NOC shift. HWD agrees to update care plan with frequency of hourly checks. Continued on 809C.... continued from 809... LPA reviewed R1's intake Appraisal/Evaluation. R1's intake indicated he has a stage 3 or 4 pressure wound at time of admission. Intake completed by Health and Wellness Director (HWD) Jody Livingston on 9/29/2023. Per LPA interview HWD, the indication of a stage 3 or 4 pressure wound was a clerical error. LPA received signed statement from HWD indicating R1 was not admitted with a stage 3 or 4 pressure wound, nor does he have a stage 3 or 4 pressure wound currently. Per LPA's observation of DOJ database inquiry, current Executive Director Morgan Holien does not have fingerprint clearance as required per Title 22 regulation 87355(d) . ED understands they must have fingerprint clearance in order to work at the facility. ED agrees to cease working at the facility until fingerprint clearance is obtained, not just applied for. ED is not associated to the facility either. ED agrees that they will pursue association to the facility before returning to facility. ED verifies that since 02/06/2023 she has been acting as Executive Director and pursuing Administrator certification and verifies that they corresponded about the process of submitting the application for Administrator certification with CCL LPA via email. Per ED, facility does not have a currently qualified and certified administrator. Facility to submit written plan indicating plan for implementation and start date of qualified and certified administrator. Plan to be submitted to CCL LPA by POC due date of 11/06/2023 Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Executive Director and a copy of this report was given.