Incident investigation·December 12, 2024

On 12/12/2024 around 04:00 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a case management for an Unusual Incident Report received regarding Resident #1 (R1). LPA met with Mary Anne Watral, Operations Specialist (OS) LPA interviewed OP and S2. LPA requested and reviewed R1's Physician's Report (LIC602), Functional Evaluation, Resident Appraisal needs and UIR dated 12/11/24. LPA confirmed that R1 can leave the facility unassisted. R1 was locked out of the facility, was able to contact his/her daughter from a passerby, and was returned to the facility on 12/04/24. As a result of R1's confusion, R1 to follow-up with the Primary Care Physician on 12/13/24. The facility has contracted an agency (RTF) to install a keyless entry pad along with a notification system at the front entrance. LPA and OP discussed recent incidents with Residents (R1, R2, R3, R4); incident reports will follow. OP self reported that an internal investigation is underway for S1 and R4. All required parties have been notified of the incidents. No deficiencies cited, exit interview conducted, and a copy of this report provided to OP.