Incident investigation·September 26, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit regarding incident report submitted to the department on 9/11/24. LPA met with Stephanie Funderburg and explained the reason for the visit. On 9/7/24 LPA Flores received incident report to notify the department of incident occurred on 8/31/24. Per incident report, on 8/31/24 at around 2:10pm resident #1(R1) left the memory care unit, had a conversation with lobby staff and left the facility unattended. Upon memory care staff conducting rounds they noticed R1 was not found. Staff contacted police department to request assistance. Police department notify facility staff R1 was found on the street and will be return to the facility. R1 was returned to the facility at around 5:10pm. LPA conducted interviews with 2 staff, per interviews conducted Lobby staff was not aware of R1 being a memory care resident. Per wellness director, upon checking the egress doors in memory care they were working, it is unknown why the staff were not aware R1 had exit the memory care, lobby staff is provided a binder with pictures of the residents that are not to leave the facility unattended to assist with identifying them. On 9/7/24 Lobby staff was given a final warning notice regarding the incident. On 9/10/24 Wellness Director provided training to staff regarding "Memory Care Secure doors, door checks", and place other measurements in place. Per physician's report R1 dementia is other treated condition and is not to leave the facility unattended. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 809D and appeal rights were provided.