Facility Evaluation Report

Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20250515120119). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation.

During the visit on 05/21/2025, LPA interviewed three (3) staff between 10:32AM-12:36PM, conducted a brief physical plant tour with Director of Nursing (DON) Jessica Saks at 12:17PM, and interviewed two (2) responsible parties/visitors of residents between 12:23PM-01:49PM. The two (2) responsible parties and three (3) staff interviewed confirmed that Resident #1 (R1) and Resident #2 (R2) have left the memory care (MC) unit on the seventh floor of Building B on multiple occasions. On 04/24/2025, R1 and R2 went to the second-floor dining room unsupervised and on 05/01/2025, R1 took the elevator outside of the MC unit to the first-floor lobby and walked outside of Building B towards Building C. In both incidents, R1 did not leave facility grounds, was found by staff immediately, and was unharmed, but R1 was unsupervised in the elevator both times that R1 left the MC floor. Staff interviews confirmed that R1 and R2 left the MC unit on the seventh floor unsupervised in the elevator. Staff also confirmed that MC can only be entered and exited with a key fob and that the elevators on the seventh floor outside of MC can only go to the first floor without a key fob and not to floors 2-6 which include the main dining room and AL units. MC residents do not get their own key fobs, their responsible parties do upon request. However, the MC exit doors to the elevator are not supervised at all times and are not delayed egress.