Incident investigation·March 11, 2025

On March 11, 2025, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with acting Administrator, Nathan Condie . On March 6, 2025, the department received an incident report from the facility. The report was regarding R1 leaving the memory care enclosed patio by climbing over the fence with the use of patio chair at approximately 7:40 AM on March 6, 2025. R1 had moved into the facility on March 3, 2025 and was still having difficulty adjusting to this new home. LPA reviewed facility records and conducted interviews with the Administrator and the med tech who was working on the morning of March 6, 2025. It was found that since admission R1 was not regularly participating in activities and continued to state a desire to leave. On the morning, R1 exited the door by her room to the patio. It was found that the batteries were low on the door alarm and the alarm was low and weak. Caregivers did not hear the alarm when R1 exited. R1 then moved patio furniture to a nearby fence. R1 scaled the fence, fell to the other side and was first responded to by workers on the other side of the fence. Caregivers then responded, R1 received medical assistance for an abrasion. LPA observed R1 today though R1 declined to be interviewed. Administrator reported that R1 is more emotionally stable and 1:1 observation has been lifted. Records review found that there were incidents and actions of R1, who has a dementia diagnosis and behavioral expressions of inappropriate behavior, confusion, aggressive behavior, depression and self harm on a physician's assessment dated March 3, 2025. ...report continued Internal staff communication documents reviewed and in places failed to consistently capture and communicate to managers from shift to shift of R1 status. Though R1 was noted to have increased ambulation instability on 3/4/25 and very confused repeated emergency pull cord use on 3/5/25, R1 continued to be intermittent checks. As a result of this inspection, 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