complaint·October 8, 2025

R1 was admitted to a different facility after discharge from the hospital. Interview with S2 revealed they attempted to contact R1’s family at the phone number listed in their documents to notify of R1’s hospitalization and subsequent discharge, but the family member’s phone number had changed and was never updated. The facility had no other way of notifying R1’s family. Record review of R1’s medical assessment revealed they had no cognitive impairment and were able to leave the facility unassisted. Review of R1’s emergency contact sheet confirmed that Family #1 (F1) was R1’s only other person to be notified in the event of an emergency. LPA attempted to call the number listed at 1:00 p.m. today and confirmed the phone number listed no longer belonged to F1. Review of an incident report submitted by the facility on 11/01/24 confirmed the details of R1’s hospitalization and discharge. Based on interviews and record review, R1 was no longer a resident of this facility when they were discovered. Therefore, R1 never wandered away from the facility and the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety concerns were observed during today’s visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.