Complaint Investigation Report

LPA interviewed resident (R1), who stated they had never been told by care companions or facility staff that they were not permitted to leave the facility. LPA also interviewed three (3) residents, who stated they are aware that staff prefer residents to stay indoors during inclement weather, however all (3) residents stated they were permitted to go outdoors if they choose to do so. Additionally, LPA interviewed an outside reporting source, who stated they no longer had information supporting the allegation and were unaware of the facility’s policy regarding residents going outdoors during inclement weather. Based on the information and evidence obtained, there is insufficient evidence to support the allegation. Therefore, the allegation is unsubstantiated.

Allegation: Staff did not keep a resident safe from harm

It was alleged that staff did not keep a resident safe from harm. This investigation consisted of interviews with facility staff, and residents. On 06/16/2026, LPA Hughes conducted a visit to the facility and spoke with the Health Services Director, who stated that staff present during the incident immediately intervened by separating the residents and providing assistance. On 07/21/2026, LPA Hughes conducted a follow-up visit to the facility and interviewed facility staff (S1) who stated that during the incident on 06/11/2026, she observed staff promptly remove resident (R1) from the area, redirect the resident, and spoke with the care companion regarding the incident. LPA also interviewed three (3) residents in care who stated they had no concerns regarding facility staff handling residents or themselves in a rough manner or failing to maintain a safe environment. Based on the information and evidence obtained during the investigation, there is insufficient evidence to corroborate this allegation. Therefore, the allegation is unsubstantiated.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.