complaint·September 10, 2025

Interviews with internal and external sources revealed that R1 does not have a responsible party. Review of R1’s medical assessment dated April 4, 2025, revealed that R1 had a primary diagnosis of Senile Degeneration of the Brain (Dementia). Per the assessment, R1’s severe cognitive impairment limits their ability to self-manage, they require assistance with all Activities of Daily Living (ADLs), and they could leave the facility unassisted, but they frequently wander and require supervision. R1 could not be used as a reliable historian to aid in this investigation due to their baseline memory loss. Interviews revealed that R1 stated on multiple occasions that they do not want to live at the facility. Interviews revealed that on June 7, 2025, R1 used their cellphone to make a phone call and arrange transportation to leave the facility. Staff then witnessed R1 packing up their personal belongings and leave in an unknown vehicle from the facility. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that the licensee conducted an unlawful eviction and lack of supervision resulted in resident eloping. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator Katherine Sandez , to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.