Incident investigation·November 9, 2021

Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced for the purpose of following up on an Incident Report. LPAs Colvin and Mixon met with Administrator Emely Rodriguez and advised of the purpose of the visit. A Serious Incident Report (SIR) was submitted to LPA Colvin in reference to an incident that occurred on 10/23/21, wherein a Memory Care resident (R1) was able to leave the facility premises unobserved. LPA Colvin interviewed Administrator Emely Rodriguez regarding the circumstances surrounding the incident and what the facility is planning to do moving forward. LPA Colvin and Mixon additionally toured the facility grounds to observe where the resident exited the facility. Administrator Rodriguez informed LPA Colvin that when the incident occurred, staff did not hear the alarm for the delayed egress on the back yard gate, and all staff were busy assisting other residents. The Administrator additionally stated that they are going to look into removing the back yard exit, which they have done for the other sister Memory Care facility (#336405887). LPA Colvin advised Administrator Rodriguez to reach out to the local Fire Department to ensure that this is acceptable for their Fire Clearance as well as general safety. LPA Colvin recommended for them to provide the Fire Marshall with a copy of their layout, and mark what changes they would like to make. LPA Colvin stated that if the Fire Marshall approves the change, the Administrator should forward the approval and copy of the new layout to LPA Colvin, along with the date of the construction and plan for how residents will be supervised during these changes. LPA Colvin additionally recommended evaluating the need for additional staff to either be on-call or unassigned to any specific building/facility, to where staff can call for their assistance, should they be unable to immediately respond to a resident exiting the facility. Since staff did not hear the alarm, LPA Colvin additionally recommended to have the alarm checked by the Fire Marshall and brainstorm other ways staff can be alerted. An exit interview was conducted with Administrator Emely Rodriguez and a copy of this report was provided.