Incident investigation·October 4, 2021

Licensing Program Analyst (LPA) Sarah Hurt arrived unannounced at the facility for a case management visit related to two incidents reported to licensing. The first incident was a fall that occurred on 09/16/2021. The second incident was an AWOL reported 9/21/21. LPA met with Business Office Manager Carlin Robertson and explained the purpose of todays visit. The facility has 67 resident at this time. LPA observed the egress door, and spoke with Carlin about the AWOL incident. The egress door alarm was not heard because of the pull chord alarms going off at the same time sounded over the egress alarm door. The normal front desk staff was assisting with coffee at the time resident left the facility and therefore no one witnessed resident walking out. LPA spoke with Carlin about the recent fall incident and even though she knew a fall took place she was not aware of the details. The incident report stated resident fell and was in her own urine and blood until staff discovered her. The incident report stated that nurse did not know how long resident was there because she missed morning rounds because it was so busy. The following deficiencies are being cited during today's inspection per California Code of Regulations, Title 22. An exit interview was conducted and a copy of the report was left at the facility.