complaint·February 21, 2025

(Continued from LIC9099 p.1) Staff interviews revealed that the elopement was a new behavior for R1, as they were noted to be a low elopement risk and had not attempted to leave the facility unassisted before this incident. Staff interviews additionally revealed that the Licensee adjusted R1's supervision level after the incident by implementing alert charting (status checks with documentation) and escorting R1 to all events. The interviews revealed that staff provided the level of supervision consistent with R1's care plan, R1 experienced a change in condition by eloping for the first time, and the Licensee immediately adjusted the care level/supervision provided to R1 after the incident. R1 was interviewed regarding the incident. R1 was not able to recall why they left the facility or which door they exited through. R1 was only able to recall the events after the incident occurred. Outside source interviews did not refute or corroborate the allegation. Attempts were made to contact the party who assisted R1 in the community after the elopement, but the source did not respond to inquiries. A second outside source familiar with the facility was contacted and confirmed being aware of the incident. However, this source did not conduct an investigation or pursue any additional information regarding the incident. Review of facility and outside source records confirmed staff statements that while R1 was not allowed to leave the building unassisted, they were not a wandering risk. R1's Elopement Risk Assessments show that R1 was a low wandering risk. R1's Needs and Services Plan, as well as an acuity assessment, showed that R1 was completely independent, with the exception of being provided reminders for bathing, using their walker and attending activities. Charting Notes for R1 were absent of any elopement or wandering incidents for R1 prior to this event. The charting notes showed that the Licensee increased their assistance/supervision to R1 after the incident; R1 was placed on alert charting and escorted to all events after the incident. Records showed that R1 explicitly requested less supervision from staff by signing a waiver not to receive checks at night. During two unannounced facility visits, LPA directly observed all facility exits. LPA observed the exits for Assisted Living to be consistent with the needs and supervision level for independent Assisted Living residents. (Continued on LIC9099-C p.3) (Continued from LIC9099-C p.2) The information gathered during the investigation did not show that the Licensee provided inadequate supervision to R1, resulting in the elopement. The evidence shows that R1 did not have a history of elopement behaviors and experienced a change in condition, and that the facility immediately adjusted the care plan to accommodate. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.