Incident investigation·October 5, 2023

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 10/01/2023. LPA met with Executive Director (ED) Bradlee Foerschner. LPA explained the reason for today's visit. On 10/02/2023, ED had called and left a voicemail message for the LPA indicating Resident #1 (R1) who resides in Traditions had been found outside about a block away from the facility. R1 does have a diagnosis of dementia and is unable to leave the facility unassisted. During today's visit, LPA interviewed ED related to the incident, LPA along with ED toured the facility at 12:45PM, all delayed egress points were tested, and LPA obtained copies of documents pertinent to the incident. ED had informed LPA that last night, one of the delayed egress points had malfunctioned and the facility has provided staff to observe the identified gate until needed repairs are made. All other delayed egress points functioned properly during today's visit. ED indicated the written incident report related to the 10/01/2023 incident would be faxed to the Regional Office within the appropriate time frame. LPA will return at a later date to continue the investigation into the incident that occurred once all written documentation has been received. No citations issued. Exit interview conducted. A copy of today's report was provided.