Incident investigation·June 19, 2025

On 6/19/2025 LPA Tryon did a Case Management Visit to the facility to look into an Incident Report from incident on June 14, 2025. SIR reported that a resident had left the facility, went down the street and fell. A bystander called 911 and resident was taken to the hospital. On this date, LPA met with Administrator Patty Uclaray at the facility. Ms. Uclaray told LPA the following: Resident R1 had no history ever of trying to leave the facility. As a matter of fact, R1 had until very recently had a car and drove. R1 has a crafting type of hobby that R1 is very involved with, and has tools to do that. R1 does NOT live in memory care, but in assisted living. Until just about a week before the incident, R1's Physician Report stated that R1 did not need supervision to leave the facility. A Physician Report done on 6/6/25 stated supervision was necessary to leave the facility. However, no attempts had ever been made; and R1 never had to be watched in that way. In the past few weeks, R1 appeared to be having some memory-type issues, that is why the updated physician visit/report was sought out. R1 had some major upsetting life events recently, that may have contributed to changes. On 6/14 resident had left without telling anyone. It was subsequently learned that R1 was going to a local store to make a purchase, so thought walking was okay. It appears R1 intended to shop and return to the facility, not to stay away. R1 did apparently fall and get a bump, but it was not a serious injury, and R1 was cleared by the ER to return. However, while at the hospital other issues were found, and R1 was kept for observation/tests. Several major diagnoses were made in the hospital this week, some of which may contribute to temporary memory issues. Administrator is visiting R1 at the hospital tomorrow to do an assessment as to whether return to Oakwood Village is appropriate; or if a more appropriate facility will need to be found. At this point, the facility did not have awareness that R1 might try to exit independently. Facility appears to have reacted appropriately once aware of the issues and is following up appropriately. No deficiency is cited today; LPA will keep informed of progress.