Follow-up·December 9, 2021

On 12/9/21, Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced to conduct a case management inspection to follow up on recent concerns brought to their attention. LPA's Mknelly and Calzada and LTCO met with Lacy Berry, Administrator on 12/2/21 regarding and incident report of R1 leaving the building unassisted. LPA informed Administrator Berry that today's visit is a follow-up to that incident. and explained purpose of inspection. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols, contacted the facility to confirm if there are any positive Covid-19 diagnoses, and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19. Additionally, LPA's were screened per Covid-19 precautionary measures upon entering the community. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 or surgical Mask. The incident report submitted 11/19/21 stated that "around dinner time", R1 was observed in the community and refused dinner when cued. Statement by administrator that around 5:45pm when the caregiver brought the resident's tray to him, R1 was not in known locations and staff conducted a search of the building and grounds. Med tech, S1, stated to LPA that she located R1 when he was observed to be entering the building by the front door. The door was unlocked and the daytime door alarm sounded. S1 stated that she had not heard the door alarm when R1 had exited the building. LPA conducted an inspection of the facility's door alarms. The front door exit/entrance is the only door to have a daytime alarm that is only loud enough for the immediate area and a night time alarm that is like all others- it is louder and continuous until reset by staff with a code. At the time that R1 left the building, there were two caregivers and a med tech who were all occupied with resident care. The receptionist had left for the day. Title 22 regulation 87303 Maintenance and Operation (i)(1)(B) requires that (i) facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more ... shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as Care staff did not hear the front door alarm when R1 exited the building. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-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. Exit interview with Administrator. Report and appeal right provided.