Incident investigation·December 30, 2024

At 8:00am on 12/30/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit related to elopement of Resident 1 (R1) on 12/24/2024. LPA met with Administrator Licensee, Arlene Ramos Lasbog announced who he is and the reason for the visit. Administrator Licensee, Arlene Ramos Lasbog and LPA conducted a advisory review of the incident that took place on 12/24/2024 of Resident R1. Administrator Licensee, and LPA reviewed facilities pre admissions appraisal process. Administrator Licensee, Arlene, and LPA reviewed staff training records and staff schedule. LPA noted that he observed 10 hours of dementia specific training and more than 20 hours of annual training for Staff 1 (S1) . Administrator Licensee, and LPA conducted a verbal advisement on resident acuity and staffing. Administrator, agreed to write a policy for pre admissions appraisal for residents, that includes staff education on new residents. Administrator also agreed to develop and implement a charting system for residents that includes daily changes in behaviors and Activities of Daily Living (ADL) needs. Administer will email a copy of pre admissions policy to LPA Jeffries by January 13th, 2025. LPA will forward general courtesy information on reporting, staff and resident files, and inspection resource material which includes link to Community Care Licensing web site. LPA advised Administrator on conducting a thorough pre admissions appraisal on all new residents with concern of resident acuity levels. Administrator agreed to conduct through pre admission appraisals on all future residents. Exit interview, report read, and report provided