Complaint Investigation Report

On 03/27/2026, LPA Marrufo obtained a copy of R1’s Individualized Service Plan (ISP), dated 08/21/2025. The Wandering section of R1’s ISP states, “Resident wanders into apartments agitating other residents. Receives observation and assistance when wandering.” The Exit Seeking section states, “Resident verbalizes desire to leave, may seek out exit doors throughout the day; will peer through door windows or loiter near exit but does not attempt to leave secured area, requiring no additional staff time. Receives observation and assistance when seeking exits. Closely observe and guide when seeking exits. Cue or redirect for safety. Resident need[s] to be on frequent checks. Lacks safety judgements.”

On 03/25/2026, the facility submitted an Unusual Incident/Injury Report (IR). The IR was submitted on 03/25/2026. The IR states that on 03/24/2026, staff last observed R1 near the Activities Director on the first floor around 4:00 PM and was brought upstairs to memory care by the Activities Director. Around 5:00 PM, staff noted R1 was missing from the Memory Care Unit. Staff called 911. Around 6:30 PM, police officers located R1 on Doyle Road.

On 03/27/2026, LPA Marrufo interviewed S1-S9. During interviews, S4, S7, S8, and S9 stated to have been involved with R1’s elopement from the facility on 03/24/2026.

During interview, S4 stated R1 took the stairway down from the Memory Care unit on the second floor to the first floor and exited the facility building through an emergency exit. S4 stated none of the staff heard the emergency exit door alarm. S4 stated he/she and other staff searched each resident room of the facility looking for R1 and then began to search for R1 in the surrounding community outside the facility building. S4 stated police found R1.

During interview, S7 stated that he/she was driving away from the facility when staff called him/her and notified him/her that R1 had eloped from the facility. S7 stated R1 had eloped from the facility about five minutes prior to S7 receiving the call from staff. S7 stated he/she began driving back to the facility while instructing staff to utilize the elopement bin, which includes the elopement checklist.