Incident investigation·June 14, 2021

Licensing Program Analyst (LPA) Natasha Persaud conducted a case management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Administrator, Alison Humora and discussed the purpose of the visit. Community Care Licensing was notified by facility representative that Resident #1 (R1) left the facility unassisted on June 9, 2021. The administrator observed R1 in their wheelchair on the sidewalk in front of the building. Per administrator, R1 was outside of the facility for approximately 8 minutes or less. R1 is not allowed to leave the facility unassisted. Per administrator, R1 was at the nursing office being monitored for medications. During that time, an emergency occurred with another resident and 911 was activated. During the emergency staff were busy attending to the emergency and didn't observe R1 exit the building unassisted. R1 returned to the facility safely with no injuries. R1 was re-assessed and provided with a wander guard device, which notifies staff if R1 attempts to exit the building from any exit. The facility has an absentee notification plan in place. No deficiencies were issued. An exit interview was conducted, and a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to Administrator via electronic mail. An electronic mail read receipt was requested to be provided upon receipt of the documents. [See LIC 811 Confidential Names List to identify Resident #1].