Facility Evaluation Report

On 06/17/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived for an unannounced case management site visit. The LPA met with Theresa Pettapiece, Designated Facility Administrator (DFA) Reshmika Sharma, Director of Resident Services (S1), and explained the purpose of the visit. The purpose of the visit was to check-in with facility administration about the Absence With Out Leave (AWOL) of a resident (R1) in their Memory Care unit, on 05/28/2025, which they self-reported by submission of a LIC624 Incident Report on 05/29/2025. The LPA conducted an interview with the DFA and S1 and requested records for review.

S1 stated that R1's behavior was unusual the evening that she eloped from the facility, including both that she was awake at that hour and that she exited the door. Because of this unusual behavior, R1 received a medical evaluation after the incident to screen for underlying issues that included a urine analysis, which came back negative. The doctor adjusted R1's depression medication and she has since been calm and responds to redirection. After the incident, facility administration conducted a staff training on the "3 P's of Elopement Prevention," and provided the LPA with a Staff Service Plan (for R1) Review Acknowledgement signed by fourteen staff. During the training, management emphasized the importance of physically checking and laying eyes on the exit doors when a door alarm goes off, as well as not turning off alarms until staff has communicated with each other and this task has been done.

The LPA requested a copy of the current and previous care plans and the LIC 602 for R1, which S1 provided. S1 stated that R1 is now classified as an elopement risk and that the new care plan included the instruction to check on her more frequently than the baseline hourly visual checks that staff performs.