Montecito Post Acute Care And Rehabilitation

alerted that resident #19 was missing at around 11:00 p.m. on August 17, 2025. LPN #86 stated that she was unsure how resident #19 was able to leave the building because doors are supposed to be alarmed and she believed that the door alarms were working.An interview with LPN #274 on September 4, 2025 at 2:13 p.m. revealed that before eloping the facility, resident #19 was observed walking around the facility's floors looking for snacks. LPN #274 stated that she left her shift at 6:30 a.m. on August 18, 2025.

She observed resident #19 returning to the facility with the facility administrator. An interview with the director on nursing (DON/staff #338) on September 4, 2025 at 2:25 p.m. revealed that according to video surveillance, residents #22 and resident #19 both left the facility using the same south door in the main lobby. DON #338 stated that this door is open every day, without alarm from 5:00 a.m. to 10:00 p.m. and that the receptionist working the front desk has pictures of each resident that is at risk for elopement.

The receptionists are scheduled daily from 8:00 a.m. to 7:00 p.m. and the entrance is not monitored 6 hours per day.

Review of the facility's 5 day investigation reports for both resident #22, dated August 22, 2025, and resident #19, dated August 25, 2025, reveal that both elopements were deemed isolated incidents.

Review of the facility policy titled Elopement, revised January 26, 2022 reveals that the facility is to provide a safe and secure atmosphere for all residents of the facility.

Among the purposes of the policy is to ensure that residents at risk of elopement are properly monitored.

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