Incident investigation·March 14, 2022

On 3-14-22 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 3-12-22. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. Regional Executive Director Jenna Silva was present and was given permission by Anuradha to sign on her behalf and accommodate LPA. LPA interviewed Administrator, regional executive director resident1 (R1) and Staff1 (S1). LPA also conducted observation on the facility’s memory care unit. On 3-14-22, facility reported to regional office an incident which occurred on 3-12-22 which involved resident1 (R1) exiting premises resulting in an absence without leave (AWOL). LPA reviewed R1’s physician report, and needs and service plan. Based on interviews and record reviews it was determined that R1 exited premises at approximately 9:30pm on 3-12-22 and returned to facility at appropriately 10:30am on 3-13-22 unharmed. According to physician’s report, R1 is not to leave facility unsupervised. LPA also reviewed staff schedule and actual hours worked for 3-12-22. Staff schedule and actual hours worked revealed 5 caregivers were on duty during the time of this incident. Interview with S1 revealed that S1 and another caregiver were attending to another resident and did not hear the door alarm sound to indicate a resident exiting. During facility observation, it was determined that alarm system is functioning properly. A review of the incident report dated 3-13-22 stated facility staff did not determine the reason for R1s AWOL. A review of physician’s report for R1 revealed that R1 has a history of wandering and indicates R1 has dementia.. Based on today’s visit. Deficiencies are cited under Title 22, Division 6. An exit interview was conducted with Jenna Silva and a copy of this report was given to Jenna. Appeal rights provided.