Incident investigation·October 29, 2025

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received on October 23, 2025. LPA met with Executive Director and explained the purpose of the visit. The incident occurred on October 22, 2025, when resident (R1) eloped from the facility. Staff observed R1 at approximately 9:30 AM and then at approximately 10 AM, R1 was no longer in their room. R1 was found nearby and returned safely to the facility. LPA observed that R1's responsible party and local law enforcement was contacted immediately. No reporting of any injuries. LPA, Executive Director and Health & Wellness Director discussed the incident and was informed that there are delayed egress at in the memory care unit. The alarm is triggered if a code is not inputted. Memory care unit is currently occupied by another community as an emergency relocation, which staffing reported there was no alarms triggered during the time of the elopement. LPA was informed when the other community moved in, they were informed to never provide the code to outside agencies to ensure the safety of residents in care. In fear that the code may have be compromised, the exit door codes has been changed. Signs has been posted for home health, hospice and other agencies to enter and exit through the memory care unity lobby to prevent any resident from "tailgating" behind others. Exit codes has been changed, R1's care plan has been adjusted, meeting was conducted with responsible party. At this time, staff will continue to monitor R1 and frequent check if R1 would like to go to outside in the courtyard. A tour of the memory care unit was conducted with Health & Wellness Director to ensure the door alarms are in working condition. LPA observed that all exits in memory care has delayed egress doors with ongoing alarms until a code is inputted. Exit interview and a copy was provided.