Incident investigation·June 7, 2023

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management visit regarding an incident report received detailing a resident elopement from the facility. LPA met with facility general manager Scott Shahade and resident care director Sarum Talivaa (Admins). Admins provided more details regarding the resident (R1) elopement. R1 is a resident that currently resides in the Garden House memory care unit and is not permitted to leave the facility unattended as stipulated in their physician's report. Admins stated that while R1 eloped from the memory care unit, they did not elope from the facility. Facility staff believes that R1 was able to exit the memory care unit while following a facility guest outside of the unit. From there, R1 went to the facility front desk en route to her old apartment in the facility's assisted living wing. R1 was noticed by front desk staff, who alerted memory care staff, who then successfully redirected R1 back to the assisted living unit. Admins reiterated that R1 never left the facility. Since the elopement, Admins have conducted multiple in-service training sessions regarding exit seeking and elopement prevention. Facility has also increased staffing levels in the Garden House, no longer contracts caregivers through outside agencies into the Garden House, changed the number combinations on the locked doors, and has hired a full time manager for the memory care unit. Facility has experienced no additional elopements since R1's incident. No deficiencies cited during today's visit. This report was reviewed with facility resident care director Sarum Talivaa and a digital copy of the report was provided via email due to printer error.