Incident investigation·November 29, 2021

Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 11/19/21. LPA met with Administrator Kim Bergan. On 11/23/21 LPA spoke with the Administrator regarding an incident report received for resident #1 (R1) indicating that R1 eloped from the facility on 11/19/21. Administrator stated that R1 followed another residents family out of the facility and was found a block away from the facility. Staff picked up R1 and they returned to the facility. R1 did not sustain any injuries. Administrator stated that based on R1's physicians report R1 is not able to leave the facility unassisted. Administrator stated that a wanderguard was placed on R1 and the memory care egress door code was changed. During today’s visit LPA toured the facility with the Administrator, review resident records and obtained copies of pertinent documents. During the facility tour at 11:37 am with the Administrator LPA observed laundry detergent in the 2nd floor laundry room accessible to residents. Administrator stated that a resident must have left the laundry detergent in the laundry room. LPA reviewed R1's records on 11/29/21 starting at 12:18 pm which revealed that R1 is not able to leave the facility unassisted. R1's care plan has been updated to reflect R1's wandering behavior. Administrator stated that R1's physician and responsible person were notified of the incident. Administrator stated that the memory care staff have been in-serviced regarding safety and elopement protocols. Administrator stated that they will be notifying all family members in writing tomorrow letting them know to make sure that no one is following them out of the memory care area. Based on the information obtained during the investigation staff failed to supervise R1 on 11/19/21 as R1 eloped from the facility. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted, todays reports were reviewed and emailed to the Administrator.