complaint·March 12, 2025

The allegation of “Facility did not provide adequate care and supervision to a resident” alleges that the facility did not provide an adequate level of supervision for resident #1 (R1) which resulted in the elopement of R1 from the facility. LPA Byrne interviewed the Administrator who informed LPA that R1 eloped from the facility’s grounds on 03/01/2025. The Administrator stated that R1 left the facility when Staff #1 (S1) was busy assisting with the care of another resident of the facility. The Administrator stated that after it was observed that R1 had left the facility, they and other facility staff searched the areas around the facility for R1. LPA confirmed with the Administrator that R1 was found by the local police department and has been placed in the hospital awaiting discharge. LPA interviewed S1 who was working at the time of R1’s elopement from the facility. S1 stated that R1 eloped during breakfast time. S1 stated that R1 left from the front door of the facility while they were assisting another resident. S1 stated that they turned the front door’s auditory alarm off in the morning, but they had the front door closed. During the physical plant tour LPA observed the front door of the facility to be equipped with a functioning auditory alarm. However, the alarm was observed to be switched off due to the front door being propped open. Based on the information obtained during interviews and physical plant tour there is sufficient evidence to support the allegation of “Facility did not provide adequate care and supervision to a resident.” Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.