Incident investigation·February 7, 2023

Licensing Program Analysts (LPA) Talwinder Bains arrived at the facility unannounced on 02/07/2023 to conduct a case management to follow up on an incident that occurred on 10/25/2022 in which R1 eloped from the facility which resulted in R1’s untimely death. LPA met with facility Administrator- Ying Lui (Ruby) and explained the purpose of the visit. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask. Department conducted an investigation which included a medical records review, residents and staff interviews regarding R1’s elopement from the facility on 10/25/22. On 10/25/2022, R1 left the facility in the afternoon to go to the store. When R1 did not return, the facility contacted local law enforcement. The facility was notified by law enforcement that R1 was in a car accident on 10/26/2022 which resulted in R1 passing away. Per R1’s Physician’s Report dated 12/16/2020, R1 was Ambulatory and notes as needing physical assistance with Activities of Daily Living(s). R1’s physician’s report indicated R1 was not confused of disoriented, did not have wandering or sun downing behavior, was able to follow simple instructions, able to communicate simple needs and was able to bathe, groom, feed, and toileting with supervision. During the investigation, it was noted that R1’s physician did not indicate whether R1 was able to leave facility unassisted. Interviews with staff indicated throughout R1’s stay at the facility, R1 would leave and come back to facility numerous times unassisted prior to this incident. Based on the investigation, R1 was alert and able to leave unassisted therefore, the facility is not liable for R1’s elopement which resulted in R1’s untimely death. No deficiency issued during this visit. Exit interview conducted and copy of the report left at the facility.