Incident investigation·January 17, 2024

At approximately 12:55pm LPA Christi Coppo arrived unannounced to conduct a case management regarding Incident Report (IR) received on 01/08/2024. LPA was greeted by greeter at front desk. Stephanie Limberg, Administrator met LPA shortly after LPA arrival. On 01/08/2024 CCL received SOC341 reporting abuse of resident (R1) by way of self-neglect. This abuse resulted in 72 hour hold and hospitalization. Admin cross reported incident to police, police report #24-271 was filed. Copy of police report not currently available. On 1/6/2024 at approximately 9:30pm R1 jumped out their apartment window, located on the second floor of Assisted Living. Staff called 911 and notified Admin immediately. R1 was transported to Santa Rosa Memorial Hospital (SRMH) via ambulance. Admin immediately notified POA and PCP. Per LPA interview with Admin, as of today, R1 remains at SRMH. R1 has a fractured back resulting from fall. Per R1's POA, R1 will not be returning to the community; the plan is to find an appropriate new community in which R1 can reside. As of now, a definitive move-out date for R1 has not been determined. If R1 does return to Ivy Park community, R1 will be reassessed prior to discharge from SRMH to ensure her care needs can be met by staff. At approximately 2:00pm LPA reviewed R1's Care Plan, Charting Notes, LIC602, and Behavior intervention record. Per Care Plan: resident is at high risk for falling. Fall risk to be mitigated by staff, encouraging R1 to use walker and sit on walker if feeling dizzy. R1 exhibits attention seeking behavior relating to medical attention and 911 services. R1 talks about wanting to die and expresses negative thoughts to others. Per charting notes: resident often claims they are dying (not that they want to die), resident's typical behavior fluctuates between negative attention-seeking behavior and self-isolation in their room. While self-isolating, resident displays various symptoms of depression. Resident pushes pendant very often, including when caregivers are already present and assisting her in her room. Resident often makes statement claims to staff related to medical misperceptions. On 12/25/2023 resident had an unwitnessed fall for which they were sent to the ER, hip and lumber spine normal per xray. Continued on 809C... Continued from 809C... Per LIC602: resident is ambulatory, has a history of depression and anxiety as well as suicidal/self-abuse, needs assistance with some ADLs, and is not able to leave facility unassisted. Per LPA interview, Admin took immediate action to mitigate future incidents of a similar nature by fitting all windows in Assisted Living with safety restrictors that prevent windows from opening more than five [5] inches (windows in Memory Care already fitted with window safety restrictors). Also, additional staff training conducted on suicide precautions and ideation. No deficiencies cited during this inspection.