Incident investigation·August 23, 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 elopement that occurred at the facility. Upon arrival, LPA met with Vice President of Operations Kathleen McCarron. Resident #1(R1) was admitted into the facility on 8/5/22. R1 resided in the Memory Care Unit (Clearbrook). On 8/18/22 at approximately 1:03pm R1 pulled a bench over to the outside exit gate and stood on it and climbed over the fence. Staff were unaware that he had left as they were assisting other residents. R1 was located in the parking lot just outside the Clearbrook building by Business Office Director and Maintenance Assistant and brought back inside. R1 was assessed with no injuries. R1 was later observed on the facility . R1's records were reviewed. R1 was not able to leave the Community without supervision due to cognitive impairment. See LIC809D for cited deficiency. An exit interview was conducted with Kathleen McCarron and a copy of this report and appeal rights were given.