Complaint·May 8, 2026

Per R1's discharge summary report dated May 4, 2026, R1 had a diagnoses of vascular dementia and Parkinson's disease. It also states that R1 needs to be monitored for behaviors such as wandering, exit - seeking, and attempting to open doors. LPA conducted interviews with two staff who were present on May 5, 2026. Both staff interviewed confirmed that on May 5, 2026, at approximately 1:30 PM, R1 exited the facility without staff supervision. Both staff stated that they noticed R1 was missing approximately twenty minutes later at 1:50 PM and they began searching nearby areas. Both staff stated that they learned at approximately 2:50 PM, that R1 was transported to the hospital after a neighbor had witnessed R1 fell on the ground. Therefore, R1 was left without staff supervision for more than an hour, and was subsequently transported to the hospital after sustaining an unwitnessed fall. LPA conducted an interview with R1's Responsible Party, Witness #1 (W1). W1 confirmed that she was informed that R1 had went missing on May 5, 2026, and was transported to the hospital after sustaining an unwitnessed fall. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegation that, facility did not provide care and supervision resulting in a resident eloping and sustaining an injury . The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D page. A civil penalty in the amount of $500.00 is also being assessed for absence of supervision. An exit interview was conducted with Administrator Hyo Kim. A copy of the report and appeal rights were provided at time of visit.