At approximately 5:27 PM, the CEO was notified by AOC via phone that while residents were in the gym, which has 2 unlocked outside doors (Leading to the fenced/Locked area). While in there, 2 residents escalated and staff walkied for support. At this time, a resident exited the gym in attempts to leave the property. One staff member followed. At this time, a staff member intercepted and was able to get to the gate opening before exited. Staff stated the gate was ajar with no chain. As the staff attempted to keep her inside the fenced area, resident saw a 2nd staff coming in for assistance and as result, escaped the staff. That was when the staff notified and he notified the CEO. CEO informed to have police called. At this time, [Recated] Director of Nurse (DON) also called CEO at 5:31 PM as she was driving home and noticed the resident. CEO informed [REDACTED] police were notified and that her number would be provided to the police if she is able to keep vision on the resident and communicate with police resulting in a hopeful quick pick up. Regional CEO was notified at 5:35 PM. At approximately 6:20 PM CEO was notified the police had located resident and DON was heading back to property and complete notification process of incident. At 6:27 PM DON was notified by police they were taking to the hospital as she stated she would “kill everyone in the building” and “suffocate all of the kids.”. CEO began communicating with sargent [REDACTED] police about next steps. It was agreed we would take the resident back for stabilization if they could transport her back to us. It was agreed police would remain present until she was safely in a locked area and a person search was conducted.

Licensing narrative: 5/11/2023- licensing emailed the facility for further information. Facility visited 5/15/23 in response to self-Report elopement of client. Gate outside of gym doors observed to be chained/Locked. Per staff report, this gate is to remain chained/locked at all times when not in use. Kitchen staff left gate unlocked when client eloped.

Regulations out of compliance: 907.2 – gate outside of gym doors observed to be chained/Locked. Per staff report, this gate is to remain chained/locked at all times when not in use. Kitchen staff left gate unlocked when client eloped. Licensing Specialist: Clayton DeBoer.