The device never got wiped down.
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Both residents have dementia and depend on staff to help them participate in programs.
During assessments, she disclosed her use of drugs and alcohol to the facility's Social Services Director.
She said she was feeling better.
The resident, identified in inspection records only as Resident 1, had been prescribed olanzapine 20 mg daily since December 2024.
The director of nursing called 911.
The resident, identified in inspection records only as R7, had already been flagged as high risk for elopement.
The incident happened on July 25, 2025.
The sequence of events, reconstructed from the inspection report, is precise and difficult to read.
This happened to the same resident, multiple times, across a single week in April 2025 at Lorien Health Systems Mt Airy.
Federal inspectors documented both failures during an August 2025 complaint inspection at the facility on Morgnec Road.
State inspectors visited Brighton Place San Diego on August 13, 2025, following a complaint about a discharge.