Incident investigation·April 8, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on a recent incident report (LIC624) submitted to the Department on March 23, 2025. LPA met with Administrator, Dana Stansel, and stated the reason for today's inspection. LPA and Administrator discussed the incident when resident (R1) was not found in their apartment at approximately 8:30 pm on March 22, 2025. Staff had been checking on resident frequently all afternoon due to them showing agitation following a visit from family. Staff immediately contacted the facility management and resident's responsible person when resident was not located inside the community. An exterior search was then conducted and resident was found walking down the street at approximately 8:55 pm. Resident stated they just wanted to take a walk and returned to the community with staff but remained agitated and displayed signs of paranoia. Resident met with emergency medical services upon returning to the community and "exhibited clear cognition" while refusing medical treatment. Resident's responsible person decided to take resident to their home and provide 1:1 care/supervision to await physician guidance and later informed the facility resident was admitted to the hospital on March 24, 2025, for reasons unrelated to the incident. The Administrator stated (R1) moved in non-ambulatory on March 13, 2025 and was very cognizant. LPA reviewed a cognitive test taken on March 12, 2025 showing resident scored 27/30, which is in the "normal" range. Resident's physician's report (also dated 3/12/25) notes (R1) has Mild Cognitive Impairment (MCI), Trimalleolor fracture on the right lower leg, is not confused/disoriented, does not show inappropriate, aggressive or wandering behavior, and is able to follow instructions/communicate needs. It appears, the physician completed additional boxes related to a diagnosis of Dementia and not MCI. Based on documentation reviewed, it appears resident had cognitive functioning within normal limits. There is not a citation issued in this report. Exit interview. Copy of report provided.