complaint·February 19, 2026

LPA interviewed administrator in which they stated they did not inform R1 that they could smoke in the gazebo area as it is against state law to smoke that close to the building entrance. Administrator stated that they did provide an alternative area for resident to smoke safely at. Administrator stated residents were not receiving any care at the time of the incident. LPA reviewed resident’s documentation which shows resident has a history of osteoporosis and other health related diagnosis. LPA reviewed hospital documentation from the visit following the incident in which it states resident was diagnosed with a spinal fracture. Due to the information gathered, LPA is unable to determine if staff neglect led to residents injury. Allegation is found to be UNSUBSTANTIATED. LPA investigated allegation, “Staff did not provide a safe environment for residents in care”. LPA interviewed relevant parties, residents, and staff and reviewed resident documentation. Relevant party stated R1 is a smoker and was told they would need to move to the smoking area at the back of the building. Relevant party stated in order to get to the smoking area from the back exit, R1 had to either step down from the curb onto the parking lot or use a ramp which had obstructions and tripping hazards. Relevant party showed LPA photos of a hose near the ramp and other boxes which could cause a tripping hazard. The smoking area was eventually moved to a different location in the front of the building that had coverage and more accessible for R1. LPA toured the facility and observed where the past smoking area was located and LPA did not see any obstruction or tripping hazards present. LPA reviewed R1’s documentation in which it states resident is non-ambulatory due to the use of a walker and has macular degeneration. Due to the information gathered, LPA was unable to determine if staff did not provide a safe environment for residents in care. Allegation is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted.