Incident investigation·November 6, 2024

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management- Incident visit. LPA met with Executive Director, Reginald Jones and discussed the purpose of the visit. The facility self reported an incident involving Resident #1 (R1). The report indicated R1 was agitated and attempting to elope from the community out of another resident's room. R1 was unsuccessful and redirected back to the hallway. R1 wore a wander guard, which alerted staff of the attempted elopement. However, staff were unable to reset it after it alerted due to R1's agitation, aggression, and refusal. The caregiver assisting R1, left R1 to assist another resident. Upon staff's return at approximately 5:30pm, R1 was not in their room or the designated floor where they reside. R1 resides in the facility's secured memory care unit with a coded elevator. R1 was able to leave the facility by sneaking pass the elevator while it was actively closing and putting their hand through to stop it. Staff searched for R1, contacted local law enforcement, and notified R1's responsible party. Local law enforcement found R1 and returned R1 to the facility at approximately 8:00pm, no injuries were sustained. ED also stated R1's responsible party wanted R1 to remain at the facility. However, another facility would be suitable. R1's responsible party agreed to transfer R1 to a higher level of care facility. R1 has a one on one companion when they are not at their program until transferred to the new secured facility. The Executive Director (ED) explained R1 moved into the facility on 10/29/24, had medication changes and and eloped on 10/30/24. The ED stated R1's responsible party indicated the change in medication could have been the cause for R1's aggression and anxiety. According to the ED R1 moved out of the facility on 11/01/24. Due to the facility's knowledge of R1 wanting to elope and not ensuring R1's safety, a deficiency was issued. Based on interviews and record review, a deficiency is being issued on t he attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]