Incident investigation·November 15, 2021

Licensing Program Analyst (LPA) Kelly Dulek initiated a Case Management - Incident visit today. LPA arrived at 01:55PM and met with Executive Director (ED) Martha Berard. Entrance interview conducted. On 10/28/2021, LPA received a phone call and voicemail from ED Berard indicating Resident #1 (R1), a Memory Care resident, had eloped from the facility. ED indicated she would send an Unusual Incident Report. On 11/02/2021, during a visit at the facility, ED Berard informed LPA that R1 had eloped again and would be sending an Unusual Incident Report. Two (2) Unusual Incident Reports were received via fax in the Woodland Hills Regional Office on 11/07/2021. During today's visit, LPA and ED discussed the Unusual Incident Reports, discussed what the facility is doing to ensure R1's safety, reviewed pertinent documents, and LPA interviewed the Memory Care Director. Following the first incident, the facility determined the door leading out of the Memory Care unit was not shutting/latching properly, allowing the resident to exit. The door was repaired on 10/28/2021, delayed egress was tested, and Wander Guard was implemented for R1. The second elopement occurred on 11/02/2021 when R1 removed the window stoppers from their window, pushed open the screen and eloped through the window. Following the 11/02/2021 incident, the facility initiated a 1:1 private caregiver for the resident, retrained staff on elopement procedures, and is changing the window stoppers in all Memory Care rooms. Additionally, R1's room's motion detectors were changed to 24-hour surveillance. During today's visit, LPA observed R1 with a private caregiver, tested the delayed egress, and conducted a tour to ensure residents' health and safety. At this time further follow up is needed. Exit interview conducted. A copy of the report was provided via email.