Incident investigation·April 12, 2022

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following the receipt of (2) Incident Reports (LIC624). LPA met with Kathleen Gilby, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms;. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. Additionally, LPA was screened upon entering the facility. The following was discussed: Resident (R1) felt light-headed on 4/2/2022 and was sent to the emergency room due to low vitals. Resident returned the following morning with no medication changes. R1 was using portable oxygen at the time of being sent out. Resident (R2) moved to facility in March 2022 with a diagnosis of Dementia. Resident was not previously living in a facility but at home. On 4/5/2022, resident was able to remove the window alarm and open the window in the activity room and climb out into the facility courtyard that is fenced. R2 was discovered in the courtyard at 8:00 am, approximately 15 minutes later. A follow up meeting was held with resident's family to discuss a better placement for resident. Resident was not injured other than minor skin tears during the incident. Administrator contacted LPA on 4/6/2022 in the afternoon. It appears the facility acted promptly with both residents. There are no deficiencies being issued today. Exit interview. Copy of report provided to Administrator.