Incident investigation·June 10, 2022

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility today to follow up on self reported reports received. The LPA met with Administrator Jill Ford at 10:31am and explained the reason for today's inspection. The LPA met with the Administrator and Nicole Hozner, Director of Health and Wellness, in the Administrator's office. On 05/28/2022, Community Care Licensing Division (CCLD) received a faxed death report pertaining to Resident#1 (R1) who passed away on 05/28/2022. The LPA reviewed facility records and discussed R1's history with the Administrator and Ms. Hozner between 11:10 AM and approximately 2:00 PM. The LPA obtained copies of pertinent records and determined further investigation is needed. At 2:03 PM, the LPA began record review for Resident #2 (R2). On 05/22/2022, the LPA received an email at 8:38pm notifying the LPA of a memory care resident elopement on 05/22/2022. The Administrator reported the resident was found unharmed by law enforcement and a written report with more details would follow. On 05/27/2022, CCLD received a faxed incident report pertaining to R2 who eloped from the facility on 05/22/2022 at approximately 12:30 AM. The report states due to a new agency caregiver, Staff #1 (S1), misunderstanding instructions given by a facility caregiver, S1 assumed it was acceptable to allow R2 leave the secured memory care unit. At approximately 12:15am, S1 inputted the door code and allowed R2 to exit the memory care unit and observed R2 get on the elevator. At approximately 12:30am, the main lobby entrance door triggered the alert system notifying staff a resident had exited the community. An internal and external facility search was conducted by staff. At approximately 12:45am, Staff #2 (S2) called 911 to report a missing resident. At approximately 12:50am, police contacted S2 to report R2 had been found at a nearby McDonald's on Wendy drive. A separate police report was made by a bystander which made R2's return back to the facility quicker. Police returned R2 back to the facility at approximately 1:00am. S2 assessed R2 upon there return and did not observe any injuries. Report continued on LIC 809-C. At 12:50am, R2's POA was contacted via telephone. The report states they informed the care giving agency that S1 should no longer be assigned to work at the facility and to ensure agency staff have thorough dementia training when assigned in memory care. Record review revealed a Missing Resident Checklist, and Resident Elopement Assessment was conducted on 05/22/2022 for R2. Records also revealed R2 has a diagnosis of dementia and is not allowed to leave the facility unassisted. A map search reflects the McDonald's were R2 was found is 0.8 miles away from the facility and takes approximately 23 minutes to walk to. At approximately 3:30pm, the LPA me with Ms. Hozner who stated she spoke with S1 on 05/22/2022 after the incident and they stated they misunderstood and thought the resident could walk around freely in assisted living. Based on the information obtained, there is sufficient evidence to issue a deficiency as staff allowed R2 out of a secured unit when they are not able to leave the facility unassisted. During today's visit when the LPA arrived, there was a "post it note" on the facility door bell indicating the bell did not work and to knock on the door for assistance The facility's entry door has been locked from the outside since the pandemic, therefore concierge opens the front door for guests. The Administrator stated the door bell stopped working recently and a part had been ordered. The LPA inquired about the protocol for late night guests, deliveries, medical personnel, etc. when the concierge is gone for the day. The Administrator stated there was a phone number posted on the door for after hours guests that calls directly to the medication room. The LPA and Administrator checked the facility door and did not observe any phone number posted. The Administrator stated the number was previously posted and immediately posted the phone number on the door during the inspection. The Maintenance Director stated the door bell would still alert the staff's Ipod's when pushed although, Ms. Hozner along with the LPA, pushed the door bell and it did not alert the Ipod Ms. Hozner had with her. Based on this information, a deficiency will be issued. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights will be emailed.