Incident investigation·December 12, 2024

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on an incident report submitted by the facility on December 10, 2024. Per the incident report submitted and reviewed, resident R1 left the community unassisted on December 10, 2024 at approximately 11:58am. R1's absence was noticed at approximately 12:25pm. 911 was called and a search performed which resulted in the resident being located and brought back unharmed to the facility. During the present visit, LPA requested R1's physician report and individual needs assessment which confirmed R1 resides in the Memory Care unit of the facility and is assessed to not be able to leave the facility unsupervised after following an unspecified staff member out of the secure perimeter of the memory care unit. Based on the incident report and records reviewed, it is thus confirmed that no supervision was provided temporarily until the resident was found approximately two and a half hours later. Since the incident, R1 has been provided with 72-hours of private caregiver supervision. All facility staff has received an updated in-service training on elopement prevention, documentation of which was obtained during the visit. Based on the evidence gathered during today's visit, a type A deficiency is being cited. An exit interview was conducted and a copy of the present report along with appeal rights was provided to a facility representative.