complaint·December 6, 2023

[Continued from 9099] Interview with Staff 1 (S1) revealed that resident 1 (R1) & Resident (R2) often leave the facility to go out in the community unassisted. S1 reported witnessing R1 & R2 leave the facility on Friday 12/1/2023 and then left as their shift ended. S1 stated that upon returning to the facility the next day (12/2/2023) they noticed that R1 & R2 had not returned to the facility. S1 admitted that they did not call the police or notify the Manager of the missing residents, as required, and was not able to provide a reason for this. S1 said they searched the local area for R1 & R2 on Saturday (12/2/2023) and Sunday (12/3/2023). S1 admitted that no one reported to any outside agency about the incident. Interview with Manager revealed that she does not work on the weekends and S1 is in charge on weekends. Manager reported that she is always available by phone and has instructed staff to notify her if there is an emergency, including missing residents. Manager stated that she has verbally told staff what to do in the event there is a resident missing. This includes search the facility grounds, immediately call her, search the local area and immediately call the police. Manager reported that she became aware of situation on Monday 12/4/2023 when she did not see R1 & R2 as she typically does. Manager asked staff about the whereabouts of R1 & R2 and she was notified that they had been missing since Friday. Manager immediately called the police to report residents missing, called responsible parties and searched the town. Manager admitted that she did not notify Community Care Licensing and did not submit an incident report until requested to do by Community Care Licensing. Review of client records revealed that according to R1 and R2’s most recent physician’s reports they are unable to leave the facility unassisted. Based on evidence obtained during visit, both allegations are substantiated. Deficiencies are cited on LIC 9099-D, per CCL Title 22 regulations. Plans of correction were jointly developed with Manager Zamora, and a paper copy of this report was provided along with Licensee Rights.