Incident investigation·September 4, 2025

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with caregiver Kevin Amoranto to discuss the purpose of the visit. Today's visit is in response to the self reported incident of Resident 1 (R1), who walked out of the facility in the middle of the night and was found on facility property. Staff interviews revealed that R1 did not leave the front yard of the facility and experienced an episode of confusion. R1 suffered minor abrasions and received medical care. Due to R1 experiencing a change in condition based on a mild cognitive impairment, consultation was provided to caregivers and Licensee regarding increased supervision and protocols to put in place to accommodate R1's new behavior of exit-seeking at night. Licensee will remain in contact with R1's Responsible Party and medical professional regarding R1's changes in condition as well as an updated care plan to accommodate R1's new behaviors. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with caregiver Kevin Amoranto, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.