Incident investigation·November 2, 2023

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct a case management inspection. LPA met with Administrator Adam Hill and Tricia Diaz, Resident Care Coordinator. LPA received a report from the facility concerning an incident that occurred on 9/11/23. R1 was a memory care resident and was found outside of the facility on the facility patio by staff. Facility investigated the incident and found that a caregiver had let R1 out of the memory care unit due to a misunderstanding. R1 was immediately brought back to the memory care unit and responsible party was notified. Administrator stated training was provided to care staff the following day. Due to the information gathered, deficiencies are cited on 809-D. Appeal rights provided. Exit interview conducted.