complaint·January 28, 2026

Regarding the allegation: Staff did not provide adequate supervision, resulting in resident eloping and sustaining injuries. It is being alleged that resident #1 (R1) eloped from the above facility, was missing for several hours and sustained injuries. During LPA's interview with R1, R1 did confirm that they left the above facility and was gone for several hours. R1 confirmed that they left early in the morning and returned around 4pm on the day they left. LPA interviewed three (3) staff, two (2) out of the three (3) staff confirmed that this is R1's second time leaving the facility. Two (2) out of the three (3) staff were present when R1 left the facility on 01/23/26. One (1) staff confirmed that they were cleaning so they did not see R1 leave the facility. Another staff did confirm that they were in and out of the facility and the front door was partially open and R1 was missing for several hours. When LPA interviewed R1, R1 did confirm they left from the front door. R1 also confirmed that they fell twice when they were walking around the streets. LPA also observed two (2) red marks on R1's facial area. LPA conducted an additional interview with a witness that confirmed this is R1's second time leaving the above facility. LPA reviewed and obtained the following documents regarding R1-Medical Assessment, Preplacement Appraisal, Resident Appraisal and Appraisal/Needs and Services Plan confirming R1 has dementia. LPA attempted to interview three (3) additional residents but to no avail did they understand and/or answer LPA's questions. Therefore, based on the record reviews and interviews conducted, the allegation is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued for the above allegation(s), an appeal rights and a copy of this report was given to the Administrator.