Facility Evaluation Report

On 1/17/25 at 12:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding a previously reported absence without leave (AWOL). LPA met with Licensee Nellen Van De Pol and explained the purpose of the visit. LPA conducted brief interview with Licensee and reviewed incident report dated 11/28/2024 as well as physician's report for R1. . Based on interview and record review it was determined that on 11/22/2024, resident1 (R1) exited facility at approximately between 4:00pm and 4:30pm. Facility staff were alerted of R1's absence after attempting to notify R1 of dinner. Facility staff searched perimeter of facility and contacted local hospitals to determine whereabouts.

It was further determined that R1 did not sign out resulting in staff unaware of R1's whereabouts and resulting in an absence of supervision. Interview and record review revealed R1 walked into local crisis center at approximately 7:00pm 11/22/2024 and excessively wet due to rain. Additionally, it was noted through record review and interview that R1 has a history of exiting facility without signing out and has a history of suicidal ideations, resulting in Licensee determining a need for "one on one care and supervision" as stated in incident report reviewed.

Incident was reported to Licensing department and local law enforcement within regulatory time frames. R1's physician's report states R1 is able to leave facility unassisted.

As a result of today's case management, citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is issued in addition to citation due to absence of supervision resulting from this AWOL. An exit interview was conducted with Licensee and a copy of this report was provided. LIC 811 and appeal rights provided.