complaint·May 30, 2024

Also it is alleged that R1 fell two times walking to the store as of December, 2023 and sustained injuries. The first fall resulted in R1 having bruises on R1’s face. The second fall resulted in a passer by finding the resident on the ground and an ambulance called. Three out of twenty staff members were interviewed and stated R1 did not leave the facility during December, 2023 and R1 did not have any injuries during that month. The three staff stated if a resident is injured, an Incident Report is completed and the Administrator is notified. All three staff stated there is no incident report regarding R1 falling during December 2023. The three staff members confirmed R1 would occasionally leave the facility to walk a few blocks to a grocery store to purchase a soda. On 2/24/2023, R1 left the facility between 10:30 pm and 10:45 pm. R1 did not sign out and did not inform staff R1 was leaving. S3 and S4 work the night shift and stated they check each residents’ rooms every two hours. At the 9:00 pm check, S3 and S4 observed R1 was asleep in R1’s room. During the 11:00 pm check, S3 and S4 discovered R1 was not in bed. Both staff members checked the entire facility and did not find R1. S3 and S4 also stated they woke R1’s roommate (R2). R2 stated did not see R1 walk out of the room. The Administrator and another staff member (S1) were immediately contacted. S1 immediately drove to the facility and drove throughout the neighborhood searching for R1. Other staff members joined the search but R1 was not found. Staff members searched for R1 from 11:30 pm until 4:00 am. The Administrator confirmed they assisted with the search & confirmed staff followed protocol. The local police department was contacted around 1:00 am and the local hospital was contacted but hospital staff confirmed R1 was not at the hospital. A staff member contacted another hospital and discovered R1 had been found by another source and was admitted to the hospital. LPA interviewed six residents on 6/21/2023 from 12:00 pm until 1:00 pm. The six residents’ rooms are on the second floor and all confirmed they did not witness a resident leaving the facility the evening of 2/24/2023. LPA received copies of the residents’ Physician’s Report and observed the six residents (R2, R3, R4, R5, R6 and R7) are able to leave the facility unassisted. All six residents confirmed when leaving the facility, residents are asked to sign out and inform staff of their destination. R2, R3, R4, R5, R6 and R7 stated there has been no issues when leaving the facility. Based upon LPA’s documentation review and interviews of staff and residents, the above allegation is unsubstantiated . Exit interview conducted and a copy of the report was given.