Incident investigation·November 18, 2022

Licensing Program Analyst Michelle Reed arrived at the facility to Conduct a Case Management visit. The visit was conducted to follow-up on an unusual incident report that was received in the Licensing Office on 11/15/22. Upon arrival, LPA met with Administrator Tyler Hawk. On 11/14/22 at approximately 7:05 am, Resident #1(R1) was observed by the Concierge outside the front door of the building. R1 was trying to come back into the facility. R1 resides in the Memory Care. Staff attempted to redirect R1 back to Memory Care. R1 became resistant and exited the front door again. The Nurse on duty and caregivers present followed. R1 proceeded to the CVS nearby and the police were contacted . R1 calmed down once law enforcement arrived. R1's family were notified and R1 was returned to the facility. A 1:1 caregiver was put into place. Administrator Tyler Hawk stated that through his investigation, it was discovered that R1 was able to exit the Memory Care at 6:50am through the delayed egress door. He exited the unit and walked out the front door. Staff were not aware that R1 had exited and it was before the Concierge had arrived. A tour of the Memory Care was conducted with Tyler Hawk and R1's records were reviewed. R1 was admitted on 9/24/22. He needs assistance with all his ADL's and cannot leave the facility unassisted. Currently there are 14 residents in the Memory Care unit. Residents were observed conducting an activity. Resident #1 was in his room and spoke briefly with LPA and Administrator Hawk. He stated he was waiting for his sister to pick him up. R1 was reassessed and a care conference was conducted with R1's Physician on 11/15/22. R1 currently has a 1:1 caregiver through the evening hours. No citation issued at this time. An exit interview was conducted and a copy of this report was provided.