complaint·February 3, 2026

Regarding the allegation : Staff refused to accept resident back to the facility. It is being alleged that Resident #1 (R1) was not being accepted back to the facility. R1 was admitted to the facility with diagnosis of dementia and required Assistance of Daily Activities (ADLs). LPA was provided copies of several Unusual Incident/Injury Reports from 04/21/2025-05/28/2025, where R1 was involved in physical altercations with staff and residents, which presented health and safety threats. On 02/10/25 R1 was diagnosed with a condition requiring use of Continuous Positive Airway Pressure (CPAP) machine nightly. Administrator informed LPA that sometime in late April 2025 POA brought in a CPAP machine, without notifying the Administrator. POA trained a former Med Tech how to put on the mask on R1 and asked the staff to monitor R1 every two hours to ensure the mask is properly placed. In May 2025 Administrator had a Care and Service Meeting with POA. Additionally, Administrator informed POA that breathing machines are considered Restricted health conditions, which are against facility’s plan of operation. Administrator informed POA that R1 might perhaps need a higher level of care. On several occasions R1 was hospitalized. On one occasion, on 05/28/2025, POA discharged R1 from hospital, without approval from facility administrator and without providing discharge report. Facility served a 30 day eviction notice on 06/17/2025, with move out date of 07/17/2025, but R1 was not evicted. Administrator informed LPA that on 07/22/2025 POA took R1 to hospital due to fever and R1 was hospitalized. Facility staff visited R1 in the hospital on 08/19/2025 and evaluated R1. It was observed that R1 is using CPAP machine in the hospital. Additionally, hospital report obtained, also states that resident has sleep apnea and requires continued use of CPAP machine at nights. Based on interviews and record review, it was determined that POA was informed of R1’s possible need for higher level of care due to behavioral issues and CPAP machine. R1 was served 30 day eviction notice on 06/17/2025. Due to higher level of care, facility is unable to provide such care, therefore the allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.