Incident investigation·November 4, 2025

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 11/04/25 to conduct a case management inspection. LPA met with staff, Preston Summerhays and explained the purpose of the visit. R1’s AWOL Incident- The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 10/31/25 regarding resident (R1) attempted to leave the facility unattended on 10/29/25 , at approximately 3PM. Per incident report, R1 was brought back to the facility uninjured by staff . Facility notified R1s doctor and family regarding this AWOL incident. R1's physician's report indicates that R1 cannot leave the facility unassisted. Although no injuries resulted from R1s AWOL incident, R1s LIC602 indicated they were unable to leave the facility unassisted. Staff reported that it was R1s first attempt to leave the facility unassisted. R2 Choking Incident- Facility submitted incident report to department on 10/31/25 about resident, R2 who had choking incident on 10/29/25 in the main dining room around 9AM. Facility staff took appropriate measures and performed Heimlick Manuever on R2. R2 was back to their baseline after this incident. Facility notified R2s family, physician and other required agencies as required. After reviewing the incident report and information gathered, it has been determined that facility took appropriate measures to address R2 s choking incident. **Report continued ......... ***Report continued .... SOC341 for residents R3,R4 --Department followed up on SOC 341 sent by facility on 10/29/25 stating that resident, R4 reported to staff on 10/29/25 that R3 punched them in their face twice in their room . Report indicated that R4 moved in to the facility on 10/28/25 and R3 was their roommate. After that incident, R4 was moved to another room. Facility notified law enforcement regarding this incident . Facility staff checked R4 for any injurers and none were present. After reviewing the incidents reports and information gathered, it has been determined that facility took appropriate measures to address these incidents and notified all required parties in timely way. No citations were observed or cited per Title 22 Regulations. Exit interview conducted and copy of the report has been provided.