Incident investigation·September 12, 2023

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/12/23 to conduct a case management inspection to follow up on a recent AWOL for R1 at the facility. LPA met with facility Business Office Manager, Danielle Twitchell and explained the purpose of the visit. LPA was screened by facility staff upon entry. R1’s AWOL Incident- The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 09/05/23 regarding resident (R1) leaving the facility unattended on 09/02/23 , at approximately 6am. Per incident report, R1 was found outside the facility unassisted by facility staff . R1 was brought back to the facility uninjured by facility staff. LPA followed up with facility after this incident and gathered information for R1 including LIC602. Facility notified R1s doctor and family regarding this AWOL incident. R1's physician's report dated 06/08/23 indicates that resident has diagnosis of dementia and cannot leave the facility unassisted. Resident has not tried to leave facility again and has been communicating better with the staff if R1 needs something. The facility has been continuously implementing measures to prevent the AWOL incidents from occurring in the future to ensure the health and safety of residents in care. No citations were issued at this time and only Technical Advisory has been issued to the facility. Exit interview conducted. Copy of report provided to facility.