complaint·July 9, 2025

Staff did not provide adequate supervision, resulting in a resident leaving the facility unsupervised. It was reported that on 04/12/24, Resident #1 (R1) left the facility unsupervised and ended up at the hospital. Interviews with the administrator and other staff revealed that the facility is not locked, and the residents can come and go as they please. Staff indicated that on 04/12/2024, R1 left the facility without signing out or notifying staff where they were going. R1 did not return to the facility, and they filed missing person’s report the following day. A review of R1’s facility record revealed that R1 is able to leave the facility unassisted and does not require supervision. Based on interviews and records review, there is insufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. Facility did not have adequate staff to meet the needs of the residents . It was alleged that on 04/13/2024, while credible witness visited the facility, there was only one staff member Staff #1 (S1) present and working at the facility to meet all residents’ needs. Interviews with staff and the Administrator revealed that the facility does have sufficient staff to provide care and supervision, as well as to meet the needs of residents in care. Staff revealed that on 04/13/24 when police arrived to the facility due to R1 missing from the facility, there were 3-4 staff present in the facility (2 caregivers, one housekeeper and a cook). Police spoke with S1 only, because S1 was assigned to assist R1. A review of the staff schedule indicated that there were at least three (03) other staff on shift on 04/13/24 (one other caregiver, one server, and a cook). Based on interviews and records review, there is no sufficient information to verify validity of the complaint. Thus, this allegation is UNSUBSTANTIATED at this time. No immediate health and safety hazards were noted at the time of this visit. Exit interview conducted. Copy of the report was issued.