complaint·April 23, 2025

Investigation revealed the following: Allegation: Lack of supervision resulted in resident eloping The detail of the complaint alleges (R1) was found wandering on the street unassisted. On 04/23/25 at approximately 2:00pm, LPA Rosser reviewed (R1) Unusual Incident /Injury Report dated 04/10/25, was having a behavioral episode, facility staff was always by (R1) side. (R1) decided to go out of the facility into the street, facility staff followed (R1) closely and redirected (R1) back into the facility. In addition, LPA Rosser observed (R1) Physician’s Report for Residential Care Facilities for the Elderly (dated 03/25/25). On the form it is marked that (R1) Secondary diagnosis impedes with her cognitive ability and it is not marked as a primary diagnosis. On 04/23/25 at approximately 11:30 AM, during an interview with the Administrator, (A1), stated staff contacted her to inform that (R1) had a behavioral episode and ran into the street followed by facility staff (S4) who redirected (R1) back into the facility. In addition, (A1) stated that (R1) was never alone when they went out into the street. On 04/23/25 at approximately 1:15 PM, during an interview with (R1) stated that they don’t recall the incident. However, (R1) stated they don’t go out of the facility alone, and they are always with someone. On 04/23/25 at approximately 12:15PM, during interviews with facility staff (S1-S4), (4) out (4) stated that they witnessed (R1) have a behavioral episode and intervened when (R1) ran into the street and redirected (R1) back into the facility. In addition, (4) out of (4) facility staff stated that (R1) was never alone when they ran outside Evaluation report continues on LIC 9099-C During this investigation, LPA found did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Brittany Kavanaugh/Administrator.