Incident investigation·October 20, 2023

At approximately 3:00pm LPAs Christi Coppo and Victoria Bertozzi arrived unannounced to conduct a case management regarding Incent Report received on 10/06/2023. Per facility’s Incident Report: On 10/05/2023 a visitor came to visit resident (R1), upon looking for R1 it was discovered that R1 was not in the facility. The last time R1 was accounted for was at approximately 2:15pm while engaging in activities in the community living room. R1 has a diagnosis of dementia and resides in Memory Care. Staff located R1 at approximately 5:15pm at the Santa Rosa Memorial Hospital Emergency room. R1 was evaluated at the hospital’s ER and was found to have no injuries, no new diagnoses, or new medication orders. R1 was released from hospital’s ER at approximately 6:07pm. LPAs reviewed R1’s assessment and clarified resident has known exit seeking behavior. Per LPAs’ conversation with Administrator, facility immediately conducted additional training with staff. Also, Administrator has increased staff monitoring of R1. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. This report was reviewed with Administrator and Appeal rights were given.