Incident investigation·November 13, 2025

On November 13, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 11/4/25. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit. The Licensee reported on, 11/4/25 at 7:45pm, Resident 1 (R1) eloped from the facility. According to the Licensee, prior to the elopement, R1 became verbally and physically aggressive towards his/her one-on-one caregiver, instructing the caregiver not to enter his/her room. The one-on-one caregiver left R1's room, leaving R1 alone. R1 then exited the facility without authorization. Police department was immediately notified. R1 was located on the street in front of the community and was escorted back to the facility. During the visit, LPA interviewed the administrator, staff and reviewed R1's file. According to staff interviewed, R1 left through the third floor exit doors and was found outside around the bushes by the first floor entrance. According to staff interviewed, at around 8:15pm, the one-on-one caregiver noticed R1 was not in his/her room and notified the med-tech on shift. Based on file reviewed, R1 has a Parkinson's Disease, is unable to leave the facility unsupervised, has unsafe wandering behaviors, and is at risk for elopement, therefore, the facility worked with the family and the family decided to hire a private caregiver through a third party agency. According to Health and Wellness Director, when a private caregiver starts working with residents at the facility, the Health and Wellness provide orientation and let the private caregivers know that if there is an incident that occurs while assisting a resident, to notify the med-tech on shift. According to the staff interviewed, the one-on-one caregiver did not endorse or notify the facility med-tech that R1 and the caregiver got into an argument and was not with R1 until the one-on-one caregiver noticed R1 was missing. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.