Incident investigation·May 3, 2024

On 5/3/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Executive Director (ED), Jessica Sanders. On 4/24/24, the department received an incident report regarding an incident involving R1 that occurred on 4/20/24. The report stated that at approximately 3:55 on 4/20/24, R1 exited memory care and then was able to leave the property unassisted. After a search of the property was conducted, local police were notified. Police located R1 several blocks from the facility. R1 was returned unharmed to the facility. In interview with the ED,ED stated an internal investigation was unable to identify when and how R1 exited the facility. Tests of the facility's delayed egress alarms found them to be functioning properly. However, the exit doors were known to at times not close all the way. Staff were to regularly check that doors were closed. There were 2 caregivers on duty at the time with 12 residents. R1 was last seen at approximately 3:15 PM, having visited the Generations Program Director's office in memory care. R1's LIC 602 and appraisal identifies R1 as having dementia, exit seeking behavior and is unable to leave unassisted. An inspection of The Villa area where R1 resided, found an exit to the parking lot one door down from R1's room and a main exit from the lobby of The Villa. The lobby from The Villa is not staffed with a receptionist. Care staff greet and allow entry to visitors. As a result of this inspection, the following deficiencies were cited on 809-D. Report reviewed. Copy of report and appeal rights provided