Follow-up on corrections·October 10, 2023

On 10/10/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver . Administrator spoke by phone and is unavailable to attend. On 9/27/23, licensee provided a statement that on 9/4/23, some time after midnight, R1 left the facility unassisted and walked to a neighbor’s yard. Facility staff (S2) was working on the overnight of 9/4/23. S2 had reportedly used the restroom and when they returned to the common area, S2 saw the front door open and that R1 had gone outside. Licensee also reported that the alarm to the front door was inoperable. Also on 9/27/23, LPA observed that the door alarm had not yet been repaired. At the time of the 9/4/23 incident R1 had a prescription for medication as needed for sleep. 8/28/23- 9/2/23, facility records show that R1 was given the medication daily for sleep. However, records did not show R1 having received the medication. The facility’s plan of operations states that all exterior doors have an operational bell/buzzer or other auditory device to alert staff when the door is opened. LPA and licensee reviewed reporting requirements related to other incidents in which R1 was involved. As a result of the investigation, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided to designee.