Follow-up on corrections·August 5, 2022

Licensing Program Analyst (LPA) LaQueena Lacy arrived at the faxcility on 8/5/2022 at 10:41am to conduct an unannounced case management visit. LPA meet with staff Alexcis Peralta and explained the purpose for this visit. A physical plant tour was conducted at 10:56am to ensure no immediate health and safety issues were present. No immediate health and safety issues were noted. The facility submitted a Serious Injury Report dated 7/29/2022 regarding resident #1 (R1) not in his room or located on the facility property. LPA requested documents relevant to the investigation at 11:26am. To investigate this incident, LPA Lacy interviewed staff #1 (S1) at 11:32am which revealed that staff conducted rounds at 10:30am and R1 was present at the facility. At approximately 12:00am staff conducted rounds and R1 was not present in the room, staff began to check the facility grounds and observed the exit gate on the left side of the building open and the cords connected to the egress gate was disconnect and pulled from the gate. Law enforcement was contacted and a report (7A21-W2) was completed. During the investigation LPA observed a ring camera located on the fence facing the exit gate, per S1, the ring camera was being charged at the time R1 exited the facility. Staff was not sure who and how the exit was monitored while the camera was charging. LPA tested the egress gate to find that the alarm was operational and functional at the time of the visit. Upon document review it was noted that R1 has Dementia and is unable to leave the facility unassisted. LPA interviewed Administrator at 12:21pm, who explained about their future plans to have better monitoring system for Dementia Resident. However, staff and Administrator were able to explain what actions they are taking to ensure health and safety of dementia residents. Based on interviews, inspection, observation and record review, It was concluded that. Continued on LIC809C The facility staff failed to provide required care and supervision to Dementia resident. Facility did not ensure that the monitoring system on all exit doors are functioning and being monitored properly. Exit interview was conducted with the S1, who was informed that since December 2021 they have at least 2 incidents in which due to neglect in care and supervision, dementia residents were able to leave the facility unassisted. On addition LPA Lacy informed S1 that AWOL of Dementia resident is posing an immediate health and safety hazard to the resident. Therefore, immediate Civil Penalty of $500.00 will be assessed at the time of this visit. No other immediate health and safety hazard is noted during this visit. Exit interview was completed, appeal rights were discussed and a copy of report was issued.