Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. The purpose of this visit it deliver the final report on a case management that was initiated on 08/25/2025 regarding an elopement that occurred on 08/20/2025. LPA met with Administrator, Lisa Lanford.

On 08/21/2025, the Department received a verbal report regarding resident (R1) who eloped from the facility on 08/20/2025. It was reported that R1 was found by a neighbor around the corner of the facility (about 450-500 feet away) around 2:00PM. The neighbor called 911 and when 911 arrived, R1 was observed disoriented and was taken to the hospital where it was found that R1 was diagnosed with an infection. It was stated that R1 did not sustain any injuries during the elopement.

Based on interview with staff (S1), around 4:15PM it was reported by another staff (S2) that R1 was missing when they were gathering all the residents for dinner time. Staff immediately went to look for R1 in all the rooms, interior and exterior of the facility but was unable to location him/her. Around 4:25PM, S1 called 911 and reported a missing resident. S1 states that while walking around the neighborhood, the police was driving by and informed S1 that R1 was found after 2:04PM and was found with no injuries. S1 states that R1 was sent to the hospital by the police due to confusion and unable to describe what happened. S1 stated that R1 returned to the facility on the same day.