complaint·April 2, 2026

LPA conducted interviews with three (3) staff members who were present at the time of R1’s fall incident. All three (3) staff members stated that R1 was found in the courtyard between a gazebo and plants on dirt. Two (2) of the three (3) staff members helped R1 up from the ground and put R1 on a wheelchair. R1 was covered in debris, dirt and ants. The staff members dusted off R1, but R1 still had some dirt on their clothes. The staff members brought R1 inside and called 911. Assessing R1 and calling 911 were the priority at the time for the staff members, not dusting off R1 for appearance. LPA attempted to interview R1, but R1 could not answer any questions due to their cognitive condition. LPA conducted interviews with five (5) other staff members, all of whom stated R1 liked being out in the courtyard playing with plants or pebbles while sitting on dirt. R1 always needed to be dusted off by staff whenever coming back inside from the courtyard. Based on file review and interviews conducted, the Department's investigation did not provide enough information to corroborate the allegation that staff are not meeting resident's hygiene needs. This allegation is unsubstantiated . It was alleged that staff allowed resident to be outside without supervision, resulting in a fall. According to the information received, R1 was allowed to be outside alone and fell at some point while unsupervised. LPA conducted R1’s file review, which revealed that R1 was ambulatory without having to use a walker or a wheelchair. R1 was not assessed as fall risk. R1 did not require one-on-one care or frequent check. LPA’s review of facility file revealed all residents were free to go outside in the courtyard for any outdoor activities. LPA observed two (2) doors leading to the courtyard. LPA also observed the courtyard to be surrounded by brick walls protected from traffic. LPA conducted interviews with eight (8) staff members, all of whom stated that all residents are free to go out in the courtyard by themselves, and no resident is under one-on-one care plan. The staff members stated residents were re-directed to come inside anytime after 20 to 30 minutes being outside. Based on file review and interviews conducted, the Department's investigation did not provide enough information to corroborate the allegation that staff allowed resident to be outside without supervision. This allegation is unsubstantiated . It was alleged that resident was left on the ground for an extended period of time. According to the information received, R1 was covered in ants, branches and dirt when emergency personnel arrived. LPA conducted interviews with three (3) staff members who were present during the time of R1’s fall incident. Staff #1 (S1) stated they assisted R1 to bed for a nap shortly after snack time at around 3:30 PM. Later, at approximately 4:40 PM, S1, along with Staff #2 and #3 (S2 and S3), began gathering residents for dinner. Continued on LIC9099-C..... S1 went out to the courtyard to see if any residents were there and found R1 lying on the ground. After briefly speaking to R1 about what happened, S1 returned inside to get help. S1 and S2 then went back outside and assisted R1 into a wheelchair. R1 was brought inside, and S2 called 911. S2 stayed on the phone until emergency personnel arrived. Both S1 and S2 stated it took about 10 minutes until the emergency personnel arrived. LPA’s interview with S3 corroborated the statements made by S1 and S2. LPA attempted to interview R1, but R1 could not answer any questions due to their cognitive condition. None of the staff members could confirm exactly how long R1 had been outside or on the ground. S1 and S2 stated that R1 was already inside the building when the emergency personnel arrived. Based on the time R1 was put to bed and the time they were found, S1 and S2 estimated that R1 could not have been outside for more than 30 to 40 minutes. Based on interviews conducted and information available, the Department's investigation did not provide enough information to corroborate the allegation that resident was left on the ground outside for an extended period of time. This allegation is unsubstantiated . A finding of Unsubstantiated means that the allegation may have occurred or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.