Incident investigation·April 3, 2025

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today and met with the Executive Director (ED), Shari Kranig, and the Health and Wellness Director (HWD), Dianne Palmer, to conduct a case management visit regarding an Unusual Incident/Injury Report received by the Department on 3/12/2025. On 3/11/2025, staff (S1) alerted the HWD that, at approximately 11:40 AM, resident (R1) was observed in the care home parking lot by staff (S2). S2 had redirected and escorted R1 back into the care home. The HWD assessed R1 and there were no injuries observed or noted. The facility notified R1's physician and responsible party of incident. Interview with HWD and ED indicated the R1 had exited memory care through the main door by following staff (S3). The alarm door to memory care did not close completely after S3 exited, which allowed R1 to follow. S2 was on their break in the parking lot and immediately observed R1 in the parking lot. S2 then redirected R1 back into the care home. HWD reviewed the elopement policy with staff and tested the alarm doors to ensure they were in working order. On 3/26/2025, the facility conducted an in-service training, which covered elopement and missing residents' resources, reducing the risk of elopement, early signs of exit seeking, missing resident policy, missing resident response worksheet, and Dementia care. There was an additional training conducted on 3/26/2025 that covered the facility's fire and elopement drill. During today's visit, no deficiencies were cited. Exit interview conducted and a copy of report provided.