LPA interviewed one (1) resident (R1) and six (6) staff members (ED, HWD, S1, S2, S3, and S4).

R1 stated that they came downstairs on their own and likely used the front lobby elevators. When asked if they had recently taken the elevator to the basement parking garage, R1 responded, “Don’t know.” When asked whether they enjoyed going outside to the patio area, R1 replied, “I don’t like to go outside.” R1 did not recall whether they had undergone surgery recently.

The Executive Director (ED) stated that there had been an incident in which R1 took the elevator to the garage, left their wheelchair there, and was later found in the Meadow Wing Memory Care Unit by a staff member who recognized that R1 did not belong in that unit. Staff member (S4) contacted R1’s family (FM) to inform them of the incident. The ED mentioned that R1 had undergone surgery prior to moving into the facility and did not have a diagnosis of dementia or mild cognitive impairment (MCI). According to the ED, R1 was capable of walking with a walker and by using hand railings and was also able to self-propel their wheelchair. R1 was described as vocal and able to express their needs clearly. The ED further stated that a technician visits the facility once per quarter to perform preventive elevator maintenance and testing, with additional service calls placed as needed between scheduled visits. The ED explained that construction equipment had been temporarily stored in the garage, surrounded by yellow caution tape, but it had been removed well before R1 accessed the garage on March 13. The ED stated that the garage area was considered very safe, no residents had previously accessed it by accident, and they could not recall any prior incidents occurring there.

HWD stated that R1 was escorted by staff from the Memory Care Unit to the Assisted Living activities room, and from there, R1 was escorted to the dining room.

S1 stated that their office was located near the Memory Care Unit, and they were notified by a staff member about a resident from the Assisted Living area being present in the Memory Care Unit. S1 observed R1 walking without the use of any assistive device.

Continued on LIC9099-C

S2 stated that they assessed R1 in the Memory Care Unit to determine whether R1 had sustained any injuries, experienced pain, or had any skin tears. S2 did not observe any skin tears or discoloration on R1’s body. S2 then contacted the Assisted Living nurse and relayed information to S4, instructing them to notify R1’s Power of Attorney (FM) and physician. S2 stated that the elevators were safe and equipped with sensors that detect obstructions, such as a hand, and prevent the doors from closing completely. S2 also stated that the basement garage was safe, noting that the door leading to the street was alarmed and would trigger a notification if opened.

S3 stated that elevator maintenance was conducted quarterly unless an issue arose that required a service call, and that the elevators had been functioning properly. A few elevator buttons had come off and were subsequently replaced. S3 mentioned that the facility underwent an annual inspection by the state; however, due to a backlog, the inspection company informed them that the letter from 2022 remained valid. This inspection letter was still posted inside the elevator. S3 explained that the elevators were equipped with a safety prevention mechanism: when the doors began to close, any interference would break a beam of light detected by a sensor, causing the doors to reopen. The doors would remain open for a designated period before attempting to close again. This feature was intended to ensure resident safety. S3 considered the garage to be safe for residents and stated that the construction materials previously stored there had been removed between January and February 2025, after being present for approximately two to three months.

S4 stated that S2 had sent them an incident report regarding R1 and instructed them to notify R1’s doctor and family (FM) about the incident in which R1 was found in the Memory Care Unit. S4 explained that S2 had conducted a head-to-toe assessment of R1 and found that R1 was neither distressed nor disoriented. S4 stated that care staff conducted hourly checks on R1, and R1 had not exhibited any exit-seeking behavior; otherwise, it may have become a recurring issue.

Continued on LIC9099-C

LPA reviewed R1’s Admission Agreement and noted that R1 moved into the facility around July 26, 2024.

LPA reviewed R1’s LIC 602 Physician’s Assessment, dated July 17, 2024. The assessment indicated that R1 was not diagnosed with dementia or mild cognitive impairment (MCI). R1’s primary diagnosis was listed as cerebral embolism. The assessment described R1’s mental condition as follows: R1 was not confused or disoriented, did not exhibit wandering behavior, was able to follow instructions, and could communicate their needs. R1 was classified as nonambulatory due to their physical condition and was noted to be recovering from surgery.

LPA reviewed R1’s progress notes dated March 13, 2025. According to the notes, staff observed R1 walking in the Meadow Wing Memory Care Unit. Staff escorted R1 back to the Assisted Living. R1 was assessed and found to have no visible injuries. R1 denied experiencing any pain or discomfort and was observed to be at their cognitive and physical baseline. R1’s wheelchair was later located in the basement garage.

LPA reviewed the facility’s Internal Incident Report Review dated March 13, 2025. According to the report, R1 was found in the Meadow Wing Memory Care Unit and was escorted to the Assisted Living activity room. R1 was observed walking without a wheelchair, which was later located in the basement garage. R1 was assessed and found to have no visible injuries and denied experiencing any pain or discomfort. R1’s primary care physician (PCP) and family member (FM) were notified. According to the follow-up comments in the report, the family member stated that that R1 wasn’t wandering and was probably looking for FM to take R1 home.

LPA reviewed the Elevator maintenance report and invoices. According to the invoices, the facility is on quarterly maintenance service. Maintenance report showed general maintenance service and other as needed service records, with the last general maintenance procedure for the hydro-hoist-way/car performed on January 08, 2025.

During the facility visit on March 20, 2025, LPA took the front elevators from the first floor to the second floor and then down to the basement parking garage.

Continued on LIC9099-C

LPA inspected the garage and observed that no construction materials were stored in the area. LPA then walked toward the second elevator located in the garage and took it up to the first floor. LPA tested the door sensors on both elevators by placing a hand between the doors as they were closing. The door sensors detected the obstruction and prevented the doors from closing. No issues were observed with the door-closing mechanisms on either elevator. Both elevators had notices posted indicating that permit renewals were in process. The garage had only one exit to the public street, which was through a sliding iron gate. This gate could be opened from the outside using a code, clicker, or by the front desk, and it could be opened from the inside when it detected an object.

LPA went to R1’s room on the second floor accompanied by the ED. R1 was not in the room. LPA saw R1 in the first-floor common area sitting on their wheelchair.

Based on observations, interviews conducted, and records reviewed, the department has determined that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegation(s) are UNSUBSTANTIATED.