Incident investigation·April 1, 2026

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Heather Myers to discuss the purpose of the visit. Today's visit is in response to the facility's self report regarding memory care Resident 1 (R1) becoming lost on a hike after being signed out of the facility by a friend. LPA collected records, conducted interviews and health and safety check for R1. Interviews and records revealed that Law enforcement and facility staff arrived on scene to search for R1 and R1's family was notified. R1 was found by law enforcement approximately 3.5 hours after R1 was identified to be missing. R1 was assessed by paramedics and placed on 48 hour alert charting for monitoring. R1 did not suffer any injuries from the incident. The facility consulted R1's family and friend regarding R1 leaving the facility. Training is to be provided to the friend for future visits, including when R1 is signed out of the facility. Additionally, R1 will be provided with a location tracker to monitor their location when away from the facility. Executive Director will provide information regarding the training provided to R1's friend, as well as any updated procedures for when R1 leaves the facility. No health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Executive Director Heather Myers, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.