Facility Evaluation Report

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 02:12PM. The purpose of this visit is to conduct an investigation regarding two self-reported incidents that occurred on 12/05/2024 and 12/22/2024. Upon arrival, the LPA met with staff and Executive Director (ED) Susan Weisbarth. Entrance interview conducted.

During today’s visit, LPA Barutyan conducted a brief physical plant tour to ensure there are no health and safety hazards and conducted interviews with five (5) staff members and attempted interviews with two (2) residents.

On 12/10/2024, the Department received an incident report stating that on 12/05/2024 around 10PM, Resident 1 (R1) eloped and left the facility unassisted through the back Egress door and had a fall on the sidewalk. Staff heard the alarm ring and noticed that R1’s room was empty. Staff checked inside and outside the facility and found R1 outside being assisted by the Fire Department, which a neighbor called in. R1 was transported to the hospital and was diagnosed with a urinary tract infection (UTI) contributing to R1’s confusion and wandering. Facility management held a meeting with R1’s responsible party to discuss changes in care such as a 1:1 caregiver for nighttime, bed/floor alarms, or relocating R1 to a room in the front of the facility.

On 12/27/2024, the Department received an incident report stating that on 12/22/2024 around 2PM, Resident #2 (R2) was spotted by Staff #1 (S1) outside of the community as R2 had eloped unnoticed. S1 recognized R2 and assisted R2 back to the facility. No injuries were noted.