Incident investigation·May 30, 2024

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced case management visit pertaining to a resident eloping from the facility. LPA met with Venca Avivi Resident Services Director and Executive Director April Princesa, who was informed the reason of the visit. LPA received (3) incident reports, pertaining to resident #1 (R1) eloping from the facility. (R1) physically moved in the facility on 05/03/2024. On 05/05/2024, (R1) was found wandering in the front parking lot of the facility, and was returned to the community. The second elopement was dated on 05/18/2024, and the 3rd was on 05/24/2024. LPA contacted the ED on 05/24/2024, to obtain further information regarding the incident. During today's visit, LPA conducted interviews and reviewed (R1s) records. (R1) is diagnosed with dementia and was currently residing on the AL (Assisted Living) side until an opening for the memory care unit was available. It was also reported to LPA that (R1's) family recently hired private companion/caregiver to accompany (R1) until (R1) could be admitted to the memory care unit. LPA was informed that (R1) will be admitted either on 05/31/2024 or 06/01/2024. (R1) is not allowed to leave the facility unassisted. LPA discussed with both the Resident Services Director & Executive Director, regarding the concerns of staffing during dining room hours and residents who are diagnosed with dementia and residing on the assisting living (AL) side of the facility, that cannot leave the facility unassisted. LPA has cited the facility for a previous incident that dealt with the same issue, dated 03/14/2024. During this visit, a citation will be issued and a civil penalty will be assessed. The ED has been informed by the LPA, that the plan of correction (POC) for today's citation will be discussed with there legal team, and ED will contact LPA on 05/31/2024 by 5pm with confirmation on the plan to correct citation. This is an immediate health and safety risk to residents in care. Citation issued, civil penalty, appeal rights, exit interview, and copy of report provided.