Brookdale Corona

Allegation investigated: Facility staff did not provide resident's authorized representative with copies of resident's records.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to issue findings for the allegation listed above. LPA stated the purpose of the visit and was granted entry and met with Administrator Brittney Martinez. The investigation consisted of staff interviews and document review. For allegation, Facility staff did not provide resident's authorized representative with copies of resident's records: Document review and interviews with staff revealed that the individual requesting copies of the resident’s records was not the primary individual listed on the resident’s legal durable power of attorney. The facility was not legally authorized to release documents to the individual that was requesting the resident’s records. The facility was not legally authorized to release documents to the secondary individual listed on the durable power of attorney due to the status of the primary individual. Unsubstantiated Based on evidence obtained during the investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Brittney Martinez, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Jul 28, 2023 · control 18-AS-20200605103755

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Administrator Brittany Martinez and was granted entry to the facility. The facility is a forty-five (45) bedroom, forty-nine (49), bathroom facility, with a kitchen/dining area, and living area. Licensed capacity is sixty (60) current census forty-two (42). LPA was accompanied by Facility Administrator Brittany Martinez to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 120 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed five (5) client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Brittany Martinez.the state’s words, verbatim · CDSS document, Jul 28, 2023

Allegation investigated: Staff neglect resulted in resident's death. Resident placed on hospice without proper authorization.

Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to deliver findings for the above complaint allegations that were initiated on 6/11/2020. LPA met with Administrator Brittney Martinez and explained the reason for the visit. For allegation, Staff neglect resulted in resident’s death: Interviews and record reviews conducted by the Department could not corroborate that R1 died as a result of staff neglect. It had been reported by facility staff that R1 was observed to have been declining in health for a short period of time prior to death. In addition, R1 was observed to be refusing to eat or drink. R1 was placed on hospice services on February 8, 2020, and subsequently passed away on February 12, 2020. Cause of death was indicated as Cerebral Vascular Disease. Unsubstantiated For allegation, Resident placed on hospice without proper authorization: Interviews and record reviews conducted by the Department could not corroborate that R1 was put on hospice without proper authorization. LPA reviewed R1’s physician’s order for hospice services dated 2/4/2020 signed by R1’s doctor. LPA also reviewed a document titled Notification of Initiation of Hospice Care Services, dated 2/10/2020 that authorized hospice services for R1 under the care of Brookdale Hospice. The document was acknowledged by R1’s power of attorney (POA). The staff stated that to initiate hospice services for a resident they are required to obtain a physician’s order and a signed statement from the resident’s POA. The facility completed both of these steps to ensure R1’s hospice needs were handled safely and correctly. Based on evidence obtained during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Brittney Martinez, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Jul 24, 2023 · control 18-AS-20200605103755

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit following a Department Complaint Investigation on 6/11/2020, complaint control number 18-AS-20200605103755. During the investigation, the Department found that R1 was not provided with the care and services needed to meet R1 needs. R1 was admitted to the facility in 2016. Physician assessment completed in 2019 indicates that R1 had dementia and a history of skin breakdown. Per additional records review and staff interviews, R1 needed assistance with all activities of daily living (ADLs) such as bathing, dressing, toileting, medication administration. R1 was also considered non-ambulatory and used a wheelchair for mobility. On January 2, 2020, R1 sustained an injury to lower left shin while being transferred by staff from wheelchair to bed. First aid treatment was done. According to facility records, on January 21, 2020, a physician determined the injury as a Stage III pressure injury (wound). Referral was made for wound care. On January 30, 2020, R1 returned from physician’s office, and it was indicated that R1 was to see home health soon. When interviewed, facility staff reported being unaware if R1 was placed on home health for treatment of the wound. In addition, a review of facility records revealed no evidence to support that R1 received wound care from home health. As a result, it is determined that facility staff failed to ensure that R1 was provided with the care and services needed to meet R1 needs. From at least January 21, 2020, until February 5, 2020, when R1 was admitted to the hospital due to poor oral intake, R1 did not receive home health treatment as needed to meet R1 needs. During today’s visit, one deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Administrator Brittney Martinez, along with a copy of LIC809D and the appeal rights.the state’s words, verbatim · CDSS document, Jul 24, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 25, 2023

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities: ...Residents in privately operated RCFEs shall have all of the following...rights: To care, supervision, & services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their needs. Based on interviews & records review, the licensee did not comply with the section cited above evidenced by not ensuring R1 received the care, supervision & services to meet their needs which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2023

Plan of correction: The licensee has agreed to read regulation 87468.2 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed send documented proof that the facility staff has been trained on the.. proper steps to initiate home health services for the residents. POC is due by 7/25/2023.

Allegation investigated: Staff are not providing access to a resident's records

This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegation mentioned above. During the course of this investigation LPA obtained and reviewed the following documentation: Identification and Emergency Information form (LIC 601) and Durable Power of Attorney (POA) paperwork for resident (R1). It is alleged that a person was requesting on behalf of R1 copies of their documentation from the facility. Review of POA paperwork indicated that R1 had appointed individuals designated on the POA. The party that was requesting R1's records was not an appointed individual on R1's POA. The facility did not have a release of information signed by the person appointed on the POA allowing the requesting party access to R1's records according to Administrator Maritza Lujan, and the paperwork could not be released at that time. Review of facility records did not reveal any court order, subpoenas for R1's records until 11/15/2021 and on 01/12/2022. Documentation was provided verifying the documents were provided. Based on the information available at this time, we have found the complaint allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred as reported. A copy of this report is being reviewed with and furnished to the facility representative. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 17, 2023 · control 18-AS-20210325120129

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility staff abandoned resident.

Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility to conclude and deliver findings for the above complaint allegation that was initiated on 12/7/2020. LPA met with Business Office Coordinator Jennifer Sanchez "Lazaro" and explained the reason for the visit. During today’s visit, LPA interviewed staff and requested and reviewed facility documents. For allegation, Facility staff abandoned resident: It was alleged that the facility did not allow Resident R1 to return to the facility due to a medical diagnosis. During interview conducted with staff, LPA was informed that the staff that sent R1 to the hospital does not work at the facility as of 8/7/2022. R1 moved out of the facility on 8/7/2021 and their whereabouts are unknown. Unsubstantiated During document review, LPA discovered R1 was sent to the hospital on 11/30/2020 due to a medical concern. R1 returned to the facility the morning of 12/1/2020. On the evening of 12/1/2020, R1 was sent back to the hospital due to further medical concerns. On the morning of 12/4/2020, R1 returned to the facility. R1 was accepted back to the facility with a medical diagnosis. LPA did not discover evidence to collaborate that R1 was abandoned by the facility. Based on the evidence found during the investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Business Office Coordinator Jennifer Sanchez "Lazaro", along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Mar 8, 2023 · control 18-AS-20201201121324

Allegation investigated: Resident was left in soiled diapers for a prolonged time. Resident's cane was taken away by facility staff. Facility did not provide a copy of resident's records to responsible party.

Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to investigate and deliver findings for the above complaint allegations. LPA met with Business Office Coordinator Jennifer Sanchez "Lazaro" and explained the reason for the visit. During today’s visit, LPA toured the facility, conducted interviews with staff and residents, reviewed and was provided facility documents. For allegation, Resident was left in soiled diapers for a prolonged time: During interviews with residents, LPA was informed that the residents’ diapers are changed as often as three (3) times a day, as well as more often as needed. LPA was not informed of a time when a resident was left in a soiled diaper for a prolonged time. Unsubstantiated During document review, LPA discovered that R1’s reappraisal/personal service plan was updated on 10/10/2020. The document was signed by a staff member but was not signed by R1’s responsible party. The facility did not provide LPA documented proof that the document was reviewed by R1’s responsible party. Based on the evidence gathered during today’s investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of evidence the standard has been met. During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Business Office Coordinator Jennifer Sanchez "Lazaro", along with a copy of the appeal rights. During interviews with staff, LPA discovered that staff check and change the residents’ diapers every one (1) to two (2) hours, as well as after each meal. If a resident soils more often, the resident will be changed more as needed. For allegation, Resident's cane was taken away by facility staff: During interviews with staff, LPA discovered that two (2) staff members remembered that R1 had times where they were aggressive with their cane. The staff remembered there was a conversation with R1’s responsible party about looking for an alternative option with R1’s doctor due to aggression. The staff could not recall R1’s cane being taken away by a staff. During document review, LPA reviewed R1’s progress notes for November 2020, December 2020, January 2021, and February 2021. LPA discovered notes detailing aggressive behavior but did not find notes stating that a staff took away R1’s cane. For allegation, Facility did not provide a copy of resident's records to responsible party: During document review, LPA was shown a folder of R1’s documents with a note on it stating to give to resident’s responsible party. LPA was also shown an email communication dated 2/4/2021 to R1’s responsible party detailing the need to send a written request for R1’s documents. On 2/11/2021, an email was sent to R1’s responsible party detailing that R1’s documents were ready to be picked up at the facility. During interview with staff, LPA discovered that R1’s documents were printed and set aside for R1’s responsible party, but they were never picked up. Overall, LPA was not given information to collaborate the three (3) allegations listed above. Based on the evidence found during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Business Office Coordinator Jennifer Sanchez "Lazaro", along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Mar 8, 2023 · control 18-AS-20210204142306

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(c) · Plan of correction due date: Mar 10, 2023

87463. Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months... Based record review, the licensee did not comply with the section cited above evidenced by reappraising and updating R1’s Personal Service plan on 10/10/2020 without informing R1’s responsible party of the changes which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 8, 2023

Plan of correction: The licensee has agreed to read regulation 87463 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to conduct a staff training to ensure residents reappraisal/personal service plan is reviewed with the resident and or their responsible party. The POC is due by 3/10/2023.

Allegation investigated: Staff do not provide proper food service to residents in care

Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to initiate and deliver findings for the above complaint allegation. LPA met with Business Office Coordinator Jennifer Sanchez-Lazaro and explained the reason for the visit. During today’s visit, LPA toured the facility, conducted interviews with residents, conducted interviews with staff, and reviewed facility documentation. For allegation, Staff do not provide proper food service to residents in care: During document review, the staff provided LPA with the breakfast, lunch, snack, and dinner menu for September and October. The menu has a variety of food groups such as: protein, dairy, vegetables, and fruits. LPA was informed that breakfast is served at 8:30 am, lunch is served at 12pm, and dinner is served at 5pm. LPA found that snacks are served at 10 am and 3pm. The residents can request additional food at any other time during the day if they are hungry outside of the serving times. Unsubstantiated During interviews with residents and staff, LPA found that the residents are being served three meals a day, along with snacks. LPA was informed that the meals are good in quantity and in taste. LPA was informed that residents are served quickly, residents are not waiting long periods of time to receive their meals, and the meals are delivered to the residents at the correct temperature. Based on information found and discovered, LPA found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted, and this report was discussed and provided to Business Office Coordinator Jennifer Sanchez-Lazaro, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Oct 4, 2022 · control 56-AS-20220929085916

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility. LPA met and toured the facility with Maintenance Director, Joe Chavez. Executive Director Brittany Martinez arrived at the end of the visit. LPA advised him of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. LPA went over COVID-19 best practices for infection control and prevention with Mr. Chavez and staff are successfully incorporating the facility's Mitigation Plan. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for local fire department has been updated. LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. LPA observed a large storage unit with an abundant supply of PPE items. Gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to residents. LPA observed multiple boxes prepared and ready to be dedicated for isolation rooms, along with trash cans to put inside and outside isolation rooms. LPA inquired as to if staff have been fit tested for N95 masks, and Mr. Chaves is not aware if staff have or have not been fit tested. Ms. Martinez has been fit tested and was able to confirm that staff have been fit tested. An exit interview was conducted where this report was discussed and provided to Ms. Martinez.the state’s words, verbatim · CDSS document, Jun 14, 2022

Allegation investigated: Staff failed to address resident's change in medical condition while in care Staff failed to seek timely medical attention for resident while in care

Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Business Office Coordinator, Jennifer Lazaro The investigation consisted of interviews and review of pertinent documents. Regarding the first allegation, Staff failed to address resident's change in medical condition while in care. Interviews with staff revealed that staff did address Resident 1’s (R1’s) change in condition by giving R1 their “as needed” medication. Medication Records indicate staff gave R1 their “as needed” medication but did not notify the facility nurse when the medication was ineffective. Staff interviews and facility records indicate that facility nurse did not notify R1’s physician or responsible party of R1’s change in condition. Regarding the second allegation, Staff failed to seek timely medical attention for resident while in care. Interviews with staff revealed staff notified R1’s physician regarding R1’s change in condition. Documents indicated that Resident 1 (R1) moved into the facility on 6/18/2020 and on 6/29/2020 document indicate R1 had a change in condition, ongoing since 6/19/2020 and it was not brought to the attention of R1’s physician in a timely manner. Substantiated Based on interviews and documentation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D. An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to Ms. Lazaro.the state’s words, verbatim · CDSS document, May 25, 2022 · control 18-AS-20200629144235

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 26, 2022

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning & that appropriate assistance is provided when such observation reveals unmet needs. When changes such as..... a physical health condition are observed, the licensee shall ensure that such changes are documented & brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement was not met as evidenced by: Staff interviews and facility records indicate that facility nurse did not notify R1’s physician or responsible party of R1’s change in condition. This poses a risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, May 25, 2022

Plan of correction: Licensee shall read the regulation in it's entirety, submit a statement of understanding, train staff on this regulation and submit a training log to CCL by the POC due date of 5/26/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(1) · Plan of correction due date: May 26, 2022

Care of Persons with Dementia: In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. This regulation was not met as evidence by: Resident 1 had a change in condition, ongoing since 6/19/2020 and it was not brought to the attention of R1’s physician in a timely manner.This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 25, 2022

Plan of correction: Licensee shall read the regulation in it's entirety, submit a statement of understanding, train staff on this regulation and submit a training log to CCL by the POC due date of 5/26/2022.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jennifer Semin conducted a case management in conjunction with complaint control number 18-AS-20200629144235. LPA met with Business Office Coordinator, Jennifer Lazaro. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence by: LPA requested to review Resident 1's (R1's) file. LPA noted several entries that met the criteria for the facility to complete and submit a special incident report (SIR) to licensing. The facility did not submit an SIR for the incidents. This poses a potential risk to residents in care. A deficiency will be cited. An exit interview was conducted where this report, LIC809D, and appeal rights were discussed and provided to Ms. Lazaro.the state’s words, verbatim · CDSS document, May 25, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211 · Plan of correction due date: Jun 1, 2022

Reporting Requirements: A written report shall be submitted to the licensing agency & to the person responsible for the resident within seven days of the occurrence of....Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requierment was not met as evidence by: LPA requested to review Resident 1's (R1's) file. LPA noted several entries that met the criteria for the facility to complete and submit a special incident report (SIR) to licensing. The facility did not submit an SIR for the incidents. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 25, 2022

Plan of correction: Licensee shall read the regulation in it's entirety, submit a statement of understanding, train staff on this regulation and submit a training log to CCL by the POC due date of 6/1/2022.

Allegation investigated: Resident wandered away due to lack of supervision

This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is to initiate the 10 day visit to investigate the above mentioned complaint allegation. LPA met with Executive Director Maritza Lujan and discussed the elements of the allegation. During this investigation visit LPA tested exit doors, delayed egress, and received training material and attendance form for an elopement overview dated 07/21/2021. It is alleged that R1 left the facility unsupervised on 07/20/2021. Based on the information reported on 07/21/2021 by Maritza Lujan and information collected through witness interviews, it is confirmed that R1 left the community on 07/20/2021 unsupervised. We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D. Substantiatedthe state’s words, verbatim · CDSS document, Jul 28, 2021 · control 18-AS-20210723121639

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Jul 29, 2021

The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. The facility has failed to meet this requirement as evidenced by R1 walking out of the facility without facility knowledge.the state’s words, verbatim · CDSS document, Jul 28, 2021

Plan of correction: Facility administrator assessed exit and exit alarm systems and provided overview training on elopement to all staff. Door codes have been changed to limit user access. When locked the front door with delayed egress and alarms are activated. There is to be a staff monitoring the lobby at all times.