Incident investigation·July 21, 2025

On 07/21/2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 07/03/2025 when the resident (R1) eloped from the facility. Upon arrival, LPA met with the Chief Operating Officer (COO), Elvyra Abare and Assistant Administrator (AAD), Beth Shirley. The LPA disclosed the purpose of the visit. LPA interviewed COO, who stated that R1’s wife (R2), was a resident of the Independent Living (IL) unit and took R1 out around 9:15 AM for AM exercise in the IL. Later around 11:45 AM, R1 called to let the Assisted Living (AL) staff know that R1 will be eating lunch with R2 at R2’s apartment at IL. R2 checked on R1 after lunch and observed R1 taking a nap. R2 took a nap as well and when R2 woke up, R1 was not in the room. A few minutes later, a private caregiver of a resident at Skilled Nursing unit saw R1 walking alone and verbally notified the staff. The Assistant Director of Nursing and one of the CNA went and brought R1 back inside the Assisted Living. A head-to-toe assessment was done and R1 was put on 72 hours monitoring. Law enforcement was not involved. COO stated that the facility held R1’s plan of care meeting with R2 and rest of R1's family members. The facility was offered an option of a private caregiver or family assisting R1 with the walks. The COO further stated that R1 likes to walk, and it would be good if R1 had a scheduled walk every day. The family decided to have R1 walk with their daughter who lives nearby. According to COO, the family stated that they are willing to sign whatever it takes for R1 to go out on walk on their own and offered to write a letter to the facility to indicate that family was liable for R1. LPA reviewed past Incident Reports and observed that R1 had dementia and have eloped from the facility twice on the same day in February 2025. Continued on LIC809-C The COO stated that the after R1's latest elopment incident, the facility has enforced the check-out and check-in procedure for R1 if anyone is taking R1 out of Assisted Living. R1 already have a wander guard bracelet on them. Additionally, R1’s family was going to provide and place an AirTag in R1’s shoes. The facility will continue to reassess R1’s well-being and safety by continuing R1’s safety discussions with R1’s family members. No deficiencies were cited during today's visit. An exit interview was conducted with the COO. A copy of this report was provided to the COO, Elvyra Abare, whose signature on this form confirms receipt of the report.