Complaint·April 23, 2026

LPA conducted interviews with three staff members. All three staff members denied the allegations. Staff denied that the facility is a hostile environment and stated that residents are treated respectfully. Staff also denied that residents are left unassisted and stated that staff are available to assist residents as needed. Staff further denied that any resident, including Resident 1 (R1), left or attempted to leave the facility unassisted. LPA attempted to interview residents; however, due to residents’ cognitive limitations, LPA was unable to obtain reliable statements from residents to support or refute the allegations. During staff interviews, staff stated that R1 could not have left the facility unassisted because R1 required assistance with ambulation and used a walker. LPA reviewed R1’s admission agreement and physician’s report. The records reviewed indicated that R1 was not receiving hospice services, had mild cognitive dementia, was non-ambulatory, and used a walker. Staff also denied any known elopement incidents involving R1 or any other resident. LPA observed exit alarms and door chimes in the facility. LPA also reviewed the Department’s system and facility records and did not observe any incident reports or records showing a known elopement incident. LPA conducted a health and safety walk-through of the interior and exterior areas of the facility. During the walk-through, LPA did not observe the facility to be a hostile environment for residents. Residents observed during the visit appeared calm and were not observed to be in distress. LPA observed staff present and available to assist residents as needed. LPA did not observe residents being left unassisted, and LPA did not observe any resident exiting or attempting to leave the facility unassisted. Regarding the allegation that the facility had no proper ventilation, LPA observed the facility to have adequate ventilation during the visit. Resident rooms inspected by LPA did not appear excessively hot or uncomfortable. LPA observed that windows were operable, the HVAC/air conditioning system was functioning, fans were present, and the thermostat was working properly. Based on the information gathered during the investigation, including staff interviews, records reviewed, and LPA’s observations, the Department is unable to determine that the allegations occurred as reported. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove or disprove that the alleged violations occurred. Therefore, the allegations are deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided to AD Paris Dumaliang. {***THIS IS AN AMENDED REPORT***}