complaint·April 22, 2026

Regarding the allegation: Staff do not prevent resident from eloping from the facility. It is being alleged that resident #1 (R1) is currently missing and has dementia. During LPA’s file review of R1, R1 did not have an updated physician report, did not have a resident reappraisal and did not have a needs and services plan. On 12/11/23, 01/05/24 and 02/05/24, R1 had a doctor stating, "R1's Psychiatric Evaluation behavior/problem/Issue is Dementia." R1 was admitted to the above facility on 06/28/23 and R1's physician report was dated 08/30/24. R1's pre-placement Appraisal was dated 03/28/23 and under service needed states R1 needs special observation/night supervision (due to confusion, forgetfulness, wandering). R1 was also under the Assisted Living Waiver which states R1 had dementia. R1 could not be interviewed because R1 never returned to the facility after they left, instead R1 was found and taken to a hospital. R1 is now transferred to a Memory Care Facility and is no longer at the above facility. During LPA's physical tour, LPA determined that there are two (2) exit doors towards the left side of the facility that are not monitored by staff and/or do not have an auditory device and/or perimeter fence gates. LPA interviewed five (5) staff that confirmed anyone can come in and out of those exit areas. One (1) staff did confirm that “R1 had left the facility a couple years ago but did return.” Another staff stated, "R1 along with other residents are not to leave the facility and the front desk is aware of it." During LPA’s interview with the front desk staff, the front desk staff did not know and could not give the LPA a list of the residents not able to leave the facility unattended/unassisted but did state, "we have cameras." LPA took a look at the cameras and five (5) of the cameras were not working. Furthermore, LPA took a picture of the cameras not working and the two (2) side exit doors where anyone can enter and exit. LPA interviewed sixteen (16) residents. Eight (8) out of the sixteen (16) residents, were residents that cannot leave the facility unassisted/unattended. Therefore, based on the LPA's observations, file review, staff and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, an appeals right was provided and a copy of this report was given to the Executive Director.