Facility Evaluation Report

On 12/22/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with the Administrator.

The department received an incident report that reported R1 having left the facility unassisted on 12/14/25. Resident returned unharmed approximately 50 minutes after their wander- guard recorded their departure. R1 was accompanied back to the facility by an apparent employee from a nearby shopping center.

Records review of R1's most recent physician's report lists: mild cognitive impairment, occasional disorientation, fall risk and unable to leave facility unassisted.

Staff interviews found that R1 has not had recent history of attempts to leave unassisted. Interviews also found that R1 had had recent discussions of wanting to get a haircut with family or staff assistance that were unsuccessful.

S1 was assigned to R1 at the time of R1's departure. S1 denies having been aware of a wander-guard alert of R1 exiting the building. S1 discovered R1 missing when S1 went to get R1 for a shower. S1 alerted others and searched the places R1 is known to go within the building.

S2 was working at the front desk at the time of R1's departure. S2 reported that the front lobby was busy at the time of R1's departure. S2 did not see R1 leave. However, S2 recalled other residents and family having been in the lobby. S2 stated that when the front door alarm sounds, staff would need to physically clear the alarm at the front door.