Incident investigation·November 6, 2025

11/06/2025 09:40 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident report that was submitted to licensing regarding an incident that occurred on 10/05/2025. It was reported that on 10/05/2025 Resident 1 (R1) and Resident 2 (R2) went on an outing and R2 reported to staff that R1 became angry and grabbed R2 by their shoulder while they were in a grocery store. R2 yelled for help and asked someone to call the police. R2 got into the vehicle with R1. R2 stated that prior to this event R1 had been driving erratically and kept asking R2 where they were and why they were there. R1 stated they did not know where they were supposed to be. R2 stated that R1 nearly rear-ended another care and was revving the engine of the vehicle. R2 got out of the vehicle at a red light, R1 was grabbing R2’s arm and said they told R2 they were looking for their gun in the vehicle and warned R2 they had better get back In the vehicle. R2 walked back to the grocery store, called the facility, and asked for someone to come and pick them up. When staff answered the phone, R2 was crying hysterically, asked for help, and asked them to come and pick R2 up. During the investigation it was learned that R1 and R2 had just moved into the facility four months prior to the incident. R1 had moved into the facility from skilled nursing and as their health improved while living at the facility decided that they wanted to live independently in their own home. R1 was having difficulty adjusting to living in the facility. Due to this the facility enlisted the services of a behaviorist for R1 to receive support services. After the incident the facility reported to Adult Protective Services, local police department, and the ombudsman. R1 and R2 moved out of the facility back to their home in October 2025. No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to Executive Director Irene Davis.