Complaint Investigation Report

R1 was ambulatory, able to communicate needs, and had mild cognitive impairment. Both documents indicate that R1 could leave the facility unassisted. Staff interviews confirmed that R1 regularly took walks outside the facility and signed themselves out daily. The sign-in/sign-out sheet shows R1 signed out twice on December 15, 2024. R1 first signed out at 9:06AM and signed back in at 9:38am. R1 then signed out at 1:27PM and did not sign back in. Both destinations were listed as "square walk clockwise."

The complaint also alleged that staff did not report R1 missing in a timely manner. LPA learned that R1 often left for walks and usually returned by evening. ED stated they called R1’s responsible party (RP) around 8:00 to 9:00 PM, which is the usual time RP brings R1 back. ED could not leave a voicemail because RP’s mailbox was full. ED also tried calling R1’s cell phone, but voicemail was not set up. RP called ED at 1:00 AM and confirmed R1 was not with them. Facility staff immediately called 911 after speaking with RP.

The third allegation stated that residents were locked out of the facility. Law enforcement found Resident 2 (R2) outside during their investigation. R2 told LPA that they were near the parking garage when law enforcement arrived and could have knocked on the door to be let in. R2 was new to the facility and did not remember the access code for the locked door. Facility confirmed residents are given an access code for entry outside public hours. R2’s physician report dated October 17, 2024, shows R2 is independent and can leave unassisted.

Based on all the evidence, the allegations are not supported. R1’s care plan and doctor’s report both show that R1 was allowed to leave the facility alone and often took daily walks. While the physician's report mentioned “needs supervision,” it also stated R1 could leave unassisted, which is contradictory. The facility called law enforcement as soon as they confirmed with R1’s responsible party that R1 was not with them. R2 is fully independent and was not locked out of the facility.

Based on interviews, record reviews, and observations, all allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are unsubstantiated.

An exit interview was conducted with Megan Amy Moore. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Megan Amy Moore whose signature below verifies receipt of these rights.