Incident investigation·December 23, 2025

On 12/22/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with the Administrator. The department received an incident report that reported R1 having left the facility unassisted on 12/14/25. Resident returned unharmed approximately 50 minutes after their wander- guard recorded their departure. R1 was accompanied back to the facility by an apparent employee from a nearby shopping center. Records review of R1's most recent physician's report lists: mild cognitive impairment, occasional disorientation, fall risk and unable to leave facility unassisted. Staff interviews found that R1 has not had recent history of attempts to leave unassisted. Interviews also found that R1 had had recent discussions of wanting to get a haircut with family or staff assistance that were unsuccessful. S1 was assigned to R1 at the time of R1's departure. S1 denies having been aware of a wander-guard alert of R1 exiting the building. S1 discovered R1 missing when S1 went to get R1 for a shower. S1 alerted others and searched the places R1 is known to go within the building. S2 was working at the front desk at the time of R1's departure. S2 reported that the front lobby was busy at the time of R1's departure. S2 did not see R1 leave. However, S2 recalled other residents and family having been in the lobby. S2 stated that when the front door alarm sounds, staff would need to physically clear the alarm at the front door. Report continued... S3 was present at the time of R1's departure and saw R1 return to the building accompanied by another person. S3 stated they were not aware of R1's departure. S4 was the med tech on shift but was on break at the time of the incident and only was aware of R1's return. A review of this incident found the following factors to have allowed R1 to leave undetected: Staff at the front desk having too many tasks at the time to fully attend to resident departures, staff not receiving alerts on pagers; and, communication between staff to confirm that a exit alarm is properly responded to and the resident has not left without assistance. Therefore, while there were sufficient number of staff, staff did not competently monitor R1 and respond to alerts of R1's exiting the facility. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided