Incident investigation·November 18, 2025

In response to Incident Reports dated 10/27/25 and 10/30/25, LPA Jeung met with director of resident services and wellness center manager/LVN for independent residents and reviewed file for client #1. After resident's reported unsupervised absences, she was evaluated by staff to require care and supervision; evaluations and assessments were documented. LPA toured facility with Ms. Rajagopal and Ms. Pascual and observed location of client #1 independent living apartment on second floor, elevators, outdoor courtyards, and path leading to care center building. On 10/27/25, client #1 told her husband that she would take a walk. About 25 minutes later, she presented at the care center building, which is on the community grounds, but in another building. On 10/30/25, client #1 was with a substitute private caregiver, who allowed client to independently walk to the dining room for lunch. She was not in the dining room nor her apartment, and was reported missing. Client did not leave the community, and was found by staff two hours later. Staff responded appropriately and client will be relocated to a higher level of care within this Continuing Care Retirement Community. No deficiency cited.