Incident investigation·May 15, 2024

On 05/15/2024, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the department received via fax on 05/3/2024. LPA met with Executive Director (ED), Ricky David and explained the purpose of the visit. The incident occurred on 05/01/2024 at approximately 5 PM facility staff observed R1 to be missing when a med tech went to R1s room to give R1 their PM medication. Facility staff conducted a search throughout the facility and it was noted that R1 was no longer in the facility. Resident was located later that night in Elko Nevada. Based on R1's LIC602 Physician's Report, signed on 10/24/2023, indicated that R1 was deemed unable to leave the facility unassisted. LPA and ED discussed ensuring that staff are aware which residents are able to leave the facility unassisted. ED informed LPA that R1 does not have a dementia diagnosis but a fall risk. LPA clarified that if the LIC602 indicates resident cannot leave unassisted then the facility is to comply. Additionally, LPA and ED discussed that R1 had recently moved from independent living to assisted living and that R1 did not want to live at the facility any longer. R1 is currently not living at the facility. As a result of the incident, deficiencies cited. Please see LIC 809-D, per Title 22 Regulations. Exit interview conducted, a copy of the report and appeal rights left at the facility.