Incident investigation·September 16, 2025

On September 16, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to follow up on an incident that occurred on 8/26/25. LPA met with Administrator, Robert Snee and explained the purpose of the visit. On 8/26/25, the Licensee reported at approximately 2:30pm, it was found that Resident 1 (R1) left the community was was observed by a caregiver driving to the facility, that R1 was walking on the sidewalk heading towards Notre Dame School. The caregiver immediately parked, approached R1 and brought R1 back to the community. No injuries were noted. Upon investigation, it was noted that the gate failed to lock. During the visit, LPA reviewed R1's file and toured the facility to observe that locks at the facility. Based on R1's file reviewed, R1 has a diagnosis of dementia. R1 has no history of elopements, however does have wandering behaviors. According to administrator and staff interviewed, the locks failed and the gate did not lock properly. Third party vendor, Lockworks Unlimited arrived the same day to fix the locks and checked all other exit gates to ensure the locks did not fail. During the visit, LPA toured the facility and observed all the exit. All gates were locked. According to the administrator, the gates were also re-keyed. No citations are issued during the visit. Report is reviewed with the administrator and a copy is provided.