Incident investigation·March 16, 2022

At approximately 10:00AM, Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Acting Administrator, Jillian Hunter. Per review of incident report, Resident, R1, was seen walking on the street and returning back to the community. Per review of R1's LIC-602/Physician's Report, report indicated that resident was not diagnosed with dementia and did not have wandering behavior. Per interview with Acting Administrator, resident did not exhibit exit-seeking behavior prior to elopement. Following elopement, resident was reassessed and was moved to a higher level of care. Per review of incident report, Resident, R2, reported pain and felt uncomfortable while receiving medical services from an outside agency. Facility reported incident to local police who are conducting their own investigation. Per conversation with Resident Services Coordinator, after incident, Facility had a staff member observe while resident received outside agency services. As of this week, resident is now receiving services previously provided by outside agency from their physician. LPAs spoke with Acting Administrator regarding Change of Administrator. Acting Administrator provided LPAs with an updated LIC-500 and confirmed that VP of Operations/Administrator is present at the facility. Acting Administrator's certificate is in pending status and once approved will be processed by LPAs for Change of Administrator. No Deficiencies cited during this visit.