Incident investigation·September 24, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on (2) incident reports regarding resident elopements. LPA met initially with Ashley Stahl, Resident Care Coordinator and then Robert Godfrey, Regional Manager and Magda Luis, Administrator. LPA discussed the incident report submitted on 8/20/24 with the Regional Director. The incident reports that on 8/20/24 (8:50 am), resident (R1) went outside with a plate of food and then was able to exit through a gate that the gardener opened. The alarm was triggered and staff were able to bring resident back to the facility, unharmed. The facility Administrator discussed this situation with the gardener who is now aware residents have a diagnosis of Dementia and cannot leave the facility unassisted. (R1) had medications reviewed and has not attempted to leave the facility again. Training was provided to staff to check all walkways when an alarm goes off to ensure all residents' safety. LPA discussed the incident report submitted on 9/10/24, for an incident occurring on 9/6/24 (7:30 pm) with Administrator Magda Luis and Regional Director, Robert Godfrey. The Administrator stated that resident (R2) went for a walk with staff member and the alarm was triggered. A few minutes later, resident (R3) was able to walk through the front door. The Regional Director stated the alarms were going when (R3) exited, and staff immediately ran out to get (R3) and bring them back to the facility. Staff who was walking with (R2) called the police for assistance in bringing (R2) back. The police arrived and brought (R3) back as (R2) returned to the facility. Elopement training was conducted with the "pm" shift. The facility took prompt action in responding to the alarm once it was triggered in both instances. Residents were returned safely. The Administrator stated she is in the process of adding (3) additional strobe lights and additional monitors, and increasing the auditory alarm in the back of the building. There are no deficiencies issued in this report. Exit interview. Copy of report provided.