Facility Evaluation Report

On June 16, 2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced case management visit at the above facility for the purpose of discussing a recent incident report.

On June 12, 2025, an incident report was submitted to CCL regarding a resident who recently eloped from the facility . On June 12, 2025 a resident (R1- see confidential names list attached) left her bedroom by way of the window. After removing the screen R1 climbed out and wandered to property adjacent to the facility at approximately 6:00 AM. R1 then contacted her family who in turn contacted the facility who verified she was not in her room. Staff immediately returned her to the facility and arranged for one on one care until it is determined that she is no longer an immediate risk to elope. A medical appointment is scheduled for this week to determine what if any medical factors are affecting her behavior. The family has been to the facility and understands the action taken and has no immediate concern over the care she is receiving. The facility has also installed new window 'warden locks' on all memory care windows. R1 had removed the previous window lock but the new ones are metal and should not be as easily removed.

Discussion was had regarding the night staff and room checks. The NOC shift previously would do room checks every two hours. Since this incident room checks have been changed from every 2 hours to every hour.

A citation under Title 22 is being issued at today's visit. The plan of correction has already been put in place and will be cleared at today's visit as well. See attached deficiency page.