complaint·January 3, 2023

Regarding allegation: Staff did not prevent a resident from wandering away from the facility . It is alleged that the facility is experiencing issues with 4 residents who reside in the Memory Care Unit, that have figured out ways of getting out, and R1 has managed to escape property grounds on 3 different occasions. After review of the resident roster, it has been noted that R1 is not a resident at this facility. The Memory Care Unit is a gated wing of the facility. Each gate door to enter/exit has a protector around the doorknob to make it difficult for residents to try to leave. If the protector is held and turned correctly, the door knob could be opened; However there is an alarm that will sound if a code is not entered in the gate system. During interviews conducted, (5) of (5) staff confirmed that R2 was the resident whom they were experiencing issues with. All staff interviewed stated that R2 was adamant about leaving the facility at any opportunity found, and found different ways of doing it. All staff state to have noticed R2 always standing by the gate and watching them enter the gate code to try to learn it. When R2 would figure out the code, R2 would use it to try to leave the facility without being noticed. Due to all staff being aware of the resident's behaviors, R2 was checked on frequently and as soon as R2 was noted not to be nearby, staff would head out to nearby stores, where R2 was noted to frequent, find R2, and bring R2 back to the facility quickly and safely. All staff interviewed stated that local law enforcement was called on one occasion when R2 was not located immediately, as it was getting dark outside. R2 was noted to have returned on one's own shortly after law enforcement had arrived to assist with locating R2. All staff interviewed state to have been on high alert regarding R2 and many different things were done to try to prevent the resident from leaving the facility unassisted, such as changing the gate code multiple times and assigning a caregiver to provide one-to-one supervision. S2 also stated to have walked with R2 to a store nearby when R2 was noted to have left the facility and refused to go back. Per S1 and S2, R2's responsible party voluntarily moved R2 to a different facility to assist with meeting R2's needs, as the responsible party was well aware of the situation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Assistant Administrator Priscilla Gaytan and copy of this report was provided.