The October 28 incident at Ararat Post Acute began when Activity Staff member AS 1 left Resident 1 unsupervised in the facility's Activity Room, assuming dietary workers present could watch the patient she knew posed an elopement risk.
AS 1 had been supervising Resident 1 in the Activity Room when her shift ended at 5:00 PM. Rather than ensuring clinical staff took over supervision, she stepped out to find Registered Nurse RN 1 at the nursing station. AS 1 told federal inspectors she informed the nurse that "someone needed to get Resident 1 from the Activity Room."
But RN 1 was beginning her 30-minute meal break and didn't realize AS 1 was ending her shift. AS 1 left the facility without confirming anyone was watching Resident 1.
Two dietary staff members remained in the Activity/Dining Room area. AS 1 later acknowledged to inspectors that "it was not appropriate to expect dietary staff to supervise Resident 1" and that she "should not have left Resident 1 unsupervised."
Nobody noticed Resident 1 was missing until RN 1 returned from her break at approximately 5:35 PM. Licensed Vocational Nurse LVN 1 informed her the patient had disappeared.
The facility called Resident 1's family around 5:30 PM. Responsible Party RP 1 and other family members immediately got in their car to search.
They found him while driving toward the facility. Resident 1 was sitting at a bus stop near a busy street intersection, 0.4 miles from Ararat Post Acute.
"Resident 1 appeared to be sweating heavily from walking," RP 1 told inspectors during a telephone interview. "Resident 1 looked lost and was surprised to see her and the other family members."
When family asked why he was there, Resident 1 didn't respond.
RN 1 had completed an elopement risk assessment when Resident 1 was admitted to the facility. She told inspectors that "all staff, including nurses and activity staff, were informed about Resident 1's high risk for elopement."
The nursing staff knew the risk. The activity staff knew the risk. But the communication breakdown happened during a shift change, leaving a vulnerable patient alone with workers not trained to supervise residents.
During RN 1's rounds before her meal break, she had observed Resident 1 with AS 1 in the Activity Room around 5:00 PM. RN 1 said AS 1 never informed her that Resident 1 needed supervision before she left.
The facility's Administrator and Director of Nursing acknowledged the failures during interviews with federal inspectors November 5.
"The supervision and safety of residents is very important, and that staff communication should be thorough at all times," the Director of Nursing stated.
The Administrator was more direct about AS 1's error: She "should not have assumed that any dietary or non-clinical staff present would be responsible for monitoring or supervising a resident."
The Administrator added that AS 1 "should have remained with Resident 1 until relieved by a clinical staff member."
Federal inspectors cited the facility for failing to provide adequate supervision and assistance to prevent accidents. The violation was classified as causing minimal harm or potential for actual harm to few residents.
The inspection report doesn't detail what happened to Resident 1 after his family brought him back to the facility. It also doesn't specify what disciplinary action, if any, AS 1 faced for leaving her shift without ensuring proper supervision of a high-risk patient.
For 35 minutes, a resident known to wander was on his own, walking along Glendale streets until his family found him sweating and lost at a bus stop.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ararat Post Acute from 2025-11-05 including all violations, facility responses, and corrective action plans.