Incident investigation·April 22, 2026

On 4/22/26, LPA Kevin Mknelly conducted a case management visit and met with Administrator. The purpose of the visit is to review a recent incident involving R1's elopement on 4/10/26. On 4/10/26, a med tech discovered R1 to not be in their room at approximately 8 PM. A search of the Assisted Living area where R1 resides found R1 to not be present. R1 returned on their own and unharmed at approximately 8:25 PM. Review of medical records found that R1 has a diagnosis of mild cognitive impairment and to use a walker as an ambulation assisted device. Interview found that experience recent episode of confusion and exit seeking and that resident had agreed to use of a wander guard. On the day of the elopement, R1 did not demonstrate active exit seeking before going to their apartment. LPA reviewed the security measures used at the community for entering /exiting the building. The front door has an alarm that is to be activated after 7 PM. The community also used the "Augi " monitoring system in resident rooms (if agreed to). In the 4/10/26 incident, staff were not alerted by the front door alarm nor the wander guard alert, allowing R1 to leave the facility unassisted until a staff check for their absence. R1's physician report on file has the recommendation that R1 not leave unassisted. R1's recent change of condition warranted a significant change for which a reappraisal was to be conducted. While a wander guard was in place, all additional measures of monitoring and procedures such as facility door alarm function and that staff would be alerted to the alarm were not verified. As a result of this inquiry, a deficiency was found. Report was reviewed with copy and appeal rights provided.