Incident investigation·February 19, 2025

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit to follow up with the case management conducted on 1/24/2025, and met with Wellness Director Blyth Obien (BO). On 1/18/2025, resident R1 was found not in the facility around 12:30PM. From the footage of the surveillance system, resident R1 left the facility without staff knowledge around 12:00PM. Facility staff searched for R1 but were unable to find R1. Facility staff notified R1's family and police. R1 was found on 1/18/2025, at 1:09PM without injury. Based on the interview with Previous Executive Director (PED), R1 exited from the building exit door #3 which is delayed egress door with 15-20 seconds delay opening mechanism and with alarm, but staff in the memory care unit at that time period did not hear alarm sounded. PED stated this is the first time R1 left the facility without staff knowledge. PED stated there is no police report case number for this incident. Based on the interview with R1's family (FM), the facility staff notified FM immediately and the facility staff searched eagerly for R1. Based on the review of R1's physician report dated 12/13/2024 and R1's care plan dated 12/12/2024, R1 has dementia, wandering behavior, and is unable to leave facility unassisted. Citation noted for today's visit. See LIC809-D. Exit interview was conducted with BO. The report was provided to BO for review and signature. A copy of the report was provided to BO.