Complaint Investigation Report

The Department reviewed several documents, including the Facility Resident Roster (dated 01/22/26), the Personnel Report LIC 500 (dated 01/21/26), (R1's) Physician’s Report LIC 602A (dated 9/11/26), the Preplacement Appraisal Information LIC 603 (dated 09/10/25), Unusual Incident Report LIC 624 (dated 01/24/26), Facility Surveillance Camera Footage (dated 01/18/26), and other pertinent records associated with this complaint.

Allegation #1: Staff did not adequately supervise resident in care resulting in resident eloping from the facility.

Allegation #2: Staff did not adequately supervise resident in care resulting in resident sustaining injuries.

It is alleged that the facility staff failed to adequately supervise Resident #1 (R1), resulting in (R1) leaving the facility without permission and resulting in (R1) sustaining injuries. Reports indicate that (R1) exited the facility unattended around 12:30 PM on Sunday, January 18, 2026. Upon (R1's) return to the facility, nursing staff evaluated (R1) and observed skinned knees, swollen palms, and bruising. This indicates that (R1) wandered out into the community unsupervised and likely fell at some point during the elopement. No further details regarding this incident were provided.

On January 26, 2026, between 11:50 AM and 12:00 PM, the Department interviewed with a staff member referred to as Staff #1 (S1). During the interview, (S1) confirmed that on Sunday, January 18, 2026, at approximately 12:36 PM, Resident #1 (R1) left the facility unaccompanied.

Video footage from that day shows (R1), who resides in room #345 on the third floor, taking the elevator down to the garage's basement level. (R1) exited through the fire exit door, which was supposed to remain unlocked under City Fire Department regulations, and walked out onto Hayworth Avenue.

(S1) explained that the video showed a visitor pressing the elevator call button in the garage while (R1) was inside the elevator. When the elevator doors opened for the visitor, (R1) exited the elevator and left the facility through the fire door. (S1) indicated that, at the time of the incident, the facility had three care staff members working on the third floor and front desk staff monitoring the surveillance security displays. Despite this, (R1) still managed to leave the facility.