Complaint·April 27, 2026

Based on an interview with the facility designated Administrator, Andrea Armstrong, she admitted that the alarm for the window did not activate when R1 kicked out the window screen like it was designed to do which allowed R1 to climb out of R1’s bedroom window on 12/02/2025. It was learned that there were sensors placed on the windows and the screens so that if any of them were triggered then the system would have activated and facility personnel would have gotten the alerts. It was learned that if this alarm had triggered like it was designed to do then the system would have notified the facility staff to respond and would have possibly prevented the elopement of R1. It was learned that this facility did not have a definite timeline of when R1 eloped from this facility and had to involve local law enforcement, facility staff, and family/friends before R1 was found and brought back to this facility. It was learned that R1 had been gone from this facility for over 8 hours before she was returned safely back to this facility. It was learned that a similar incident of elopement for R1 took place on 11/29/2025 where R1 was able to exit the memory care unit and was later found in the Assisted Living portion of this facility. It was unknown to the facility staff and responsible parties for R1 as to how R1 was able to leave the secured perimeter of the memory care unit when it was equipped with a keypad before exiting and how the alarms were not triggered at that time. Based on a review of the forms and documents gathered during this investigation, it was learned that R1 moved into this facility on 10/31/2025 and had an initial assessment performed by this facility on 11/07/2025. A review of the Individualized Service Plan was conducted for R1 at this time. It was learned that a second assessment was conducted and completed on 12/05/2025 after the elopement incident which took place on 12/02/2025. It was observed that there weren’t any major changes noted on the updated assessment except for language addressing the risk for elopement and the staff’s responsibility to perform checks on R1 to redirect/reorient R1 when it was observed that R1 was gravitating towards facility exits. It was learned that all other areas regarding behaviors, Activities of Daily Living (ADLs), and Special Medical Needs were unchanged at this time. It was learned that R1 did not exhibit any behaviors which were a threat to R1 nor a threat to any other residents in care. Based on a review of the forms and documents gathered during this investigation, it was learned that One on One Supervision for Emergency Situations was an additional item and service that was elected by the resident, and their responsible parties, upon admission to this facility. It was learned that this item and service was not elected upon admission for R1. It was learned that this One-on-One service was implemented by this facility after the elopement incident for R1. It was learned that the One-on-One Care or Supervision could only be implemented if a resident was deemed to be a danger to themselves or others. Based on the updated assessment completed on 12/05/2025 R1 was never deemed to be a threat to themself or to others. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interview