Incident investigation·February 20, 2025

On 02/20/25 at 2:43PM, Licensing Program Analyst (LPA) Daisy Panlilio arrived unannounced to conduct a case management visit in response to a priority 1 complaint received on 04/09/24. LPA met with Executive Director (ED) and explained the purpose of the visit. Reporting party (RP) stated that review of video footage on 03/03/24 showed a male memory care resident (R5) entered resident's (R1) bedroom at 0449 hours and stayed there until 0600 hours. RP stated that R1's bedroom had a motion sensor that would alert staff of any movements inside. RP stated that no staff came to remove R5 from R1's room. R5 left the room on his own at 0600 hours. RP also stated she observed memory care residents left unsupervised in the common room of the memory care unit while she was visiting R1 on May 2024. LPA interviewed ED who stated that he discussed the incidents with RP and conducted in-service staff retraining regarding proper care and supervision of residents with dementia on 04/12/24. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.