| 02/03/2025 10:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Irene Davis. Today’s visit is regarding an incident that was reported to licensing on 01/20/2025 regarding an incident that occurred on 01/11/2025.
It was reported that Staff 1 (S1) was doing status check rounds on the residents and didn't see Resident 1 (R1). S1 then searched all rooms in the memory care unit. When S1 couldn't find R1 she notified the resident services director (RSD). RSD implemented the elopement protocol to search the facility, getting all staff engaged. It was reported that no elopement alarms were heard. Staff were sent to each hall - every exit and front and back grounds. Staff announced over the walkie, they found R1 and escorted R1 back to the memory care unit. R1 had walked outside using the exit by unit 237 laundry room. Resident 2 (R2) was outside walking their dog and saw R1 exit 237 back door. R2 escorted R1 back into the community and was walking her down the hall to R1's apartment. Staff 2 (S2) saw R1 walking with R2 and escorted R1 back to the memory care unit without incident.
During the investigation it was learned that R1 had walked out of the memory care unit, possibly exited with visitors. R1 walked down the hall to the stairway and was exiting the building when they were escorted back inside by another resident. R1 had been outside of the memory care unit for a total of 10 minutes.
In order to prevent this from happening again the facility conducted an elopement drill, increased staff checks for R1. The facility is trying to keep R1 more engaged in activities and has offered to take R1 on shopping trips but R1 has refused. The facility has notified visiting families to be cautious when exiting the memory care unit to ensure that residents do not walk out with them.
No deficiencies were cited as a result of today’s visit. Exit interview conducted and a copy of the report was provided to with Executive Director Irene Davis.
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