Incident investigation·April 4, 2022

Licensing Program Analyst Michelle Reed arrived at the facility to conduct a case management. The visit was conducted to discuss two unusual incident reports sent to the Department on 3/17/22 and 3/28/22. Upon arrival, LPA met with Administrator Tammie Sampedro. A tour of the Clearbrook Building (Memory Care) was conducted and records were reviewed for Resident #1 and Resident #2. On 3/10/22 R1 was admitted into the Community. According to records reviewed R1 resides in the Assisted Living Building. R1 cannot leave the facility unassisted and according to her care plan, has a history of wandering behavior. There was a wander guard put in place, but R1 took it off. On 3/11/22 at approximately 7:30 am, R1 was outside the front door trying to get back in to the building. The Concierge arrived for work and let her inside. At approximately 9:15am the Concierge received a call from the Sunrise Community down the street (quarter of a mile) that R1 was at their building trying to come inside. The police had been called and R1 was returned to the Community. On 3/12/22 R1 left the Community again, and the Maintenance Director brought her back. R1 was down the street from the building. He saw her down the street from the building on his way into work. R1 had also expressed wanting to hurt herself. R1 currently has a 1 on 1 caregiver and was seen by her doctor. R1 did not receive any injuries. On 3/27/22 at approximately 5:45pm, R2 could not be found in the Memory Care building. A search of the building as well as the Assisted Living was conducted and law enforcement was contacted. R1 was found down the street in the area of Newport and 17th Street by staff and law enforcement and returned to the Community with no injuries. R1 was placed on frequent status checks. See LIC809D for cited deficiencies. An exit interview was conducted with Administrator Tammie Sampedro and a copy of this report and appeal rights were provided.