complaint·December 19, 2025

Continued from LIC9099 While riding the elevators, LPA spoke with multiple staff and residents also riding the elevators who all confirmed neither elevator had been down for longer than a few hours for service. ED provided the elevators scheduled maintenance records showing that on 11/21/2025 passenger elevator 2 got stuck between floors with no one on board. A technician arrived at 9:23 AM and by 1:08 PM left with the elevator back in service. Records show at no point either elevator being out of service for longer than a few hours. Based on the information obtained and observation, this allegation is unsubstantiated. Allegations: Staff do not ensure residents are provided supervision Investigation Findings: It was reported to the department that a resident will spend hours outside picking up leaves and no staff member or person ever goes out to help that resident. During the investigation, LPA walked around in front of the facility and encountered R1 getting ready to pick up leaves. R1 informed LPA that R1 enjoys cleaning up leaves as it provides exercise and fresh air, R1 checks the weather, dresses appropriately for comfort and mobility, and has the sense to not go out when it is raining. R1 was lucid, oriented and showed no signs of dementia or cognitive impairment. R1 is independent and prefers independent activities to social activities. LPA spoke with ED who confirmed R1 is checked on by staff and is not fond of social activities in the facility. A review of R1’s physicians Report shows R1 may leave independently with no escort and has no cognitive impairment. Based on the information obtained, observation and interviews, this allegation is unsubstantiated. Allegations: Administration qualifications Investigation Findings: It was reported to the department that the administrator quit. LPA spoke with the administrator, ED, and verified the ED had not quit. Based on observation and interview, this allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.