Incident investigation·May 15, 2025

On May 15, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on 5/1/25. LPA met with Administrator, Siobhan Surraco and explained the purpose of the visit. The Licensee reported on 5/1/25 at 2pm, care staff reported that they heard the patio door alarm sounding and noticed that Resident 1 (R1) had exited the secured memory care unit without staff supervision. Staff reported they last saw R1 at around 1:50pm in his/her room. R1 was found a half a block away at around 2:10pm with no injuries and unharmed. During the visit, LPA toured the memory care unit, reviewed R1's file, interviewed the administrator and the Resident Care Director (RCD). Based on medical records dated 11/2024, R1 has mild cognitive impairment (MCI). R1 does not have a history of wandering behaviors based on file reviewed. According to the Administrator, R1 resides at the memory care unit with his/her significant other. R1 left the facility through the memory care outdoor terrace door to the outdoor terrace area and walked to the side of the terrace then left through the second door to get outside the facility. Both doors were observed to be delayed egress doors. Both delayed egress doors were observed to be in functioning condition. According to the administrator and RCD, they are unsure how R1 left without staff noticing but believe that R1 left the facility unassisted during shift change. LPA was unable to interview staff who were present during the incident as they were not present at the facility. Further investigation is required. No citations are issued during the visit. Report is reviewed with Administrator and a copy is provided.