complaint·March 18, 2026

Interview with Executive Director (ED) revealed the facility operates a transportation service daily on weekdays from 8:00 A.M. to 4:00 P.M. The ED explained that residents submit transportation requests through the concierge, and staff verify the address provided; however, staff do not question the purpose of the trip. ED confirmed they were informed of the incident with R1 and noted R1 independently scheduled the appointment which was not directed by staff. Interview with R1 corroborated the ED’s statements. R1 reported that they independently searched for a dentist online and misunderstood the services being provided at the destination they requested. R1 also stated that the driver was contacted immediately after the error was realized and returned within approximately two to three minutes of drop-off. Interview with Staff 2 (S2) indicated that they dropped off R1 and waited until they visually confirmed R1 entered the building. S2 reported they had only just begun to drive away and were still in the parking lot when they received the call to return. S2 stated they acknowledged the request and returned R1 safely back to the facility. A review of the transportation log confirmed that R1 independently requested off-site transport on March 11, including the date, time, and address. A review of medical documents, including the needs and services plan, noted that R1 is able to transfer safely with or without assistance. Additionally, the medical assessment indicates that R1 is permitted to leave the facility unsupervised. A review of the Admissions Record, R1 lists self as responsible party and is able to make their own decisions independently. Based on interviews, research, and record review, the allegations staff left resident unattended at an off-site location is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Executive Director Jimmy Stewart.