complaint·October 7, 2025

After the repairs were completed, R1 informed the LPA that the shared room was more comfortable and spacious and expressed a desire to remain there. R1 acknowledged being fully aware that the room is designated for shared occupancy and agreed to the possibility of having a roommate. R1 stated being happy, content, and wishing to stay in the shared space. Although it was reported that the facility was not following the Admission Agreement, evidence shows that R1 voluntarily chose to remain in the shared room, exercising their personal rights. Therefore, based on interviews and record reviews, there is insufficient evidence to prove or disprove the allegation. The allegation is deemed Unsubstantiated. Allegation #2: Staff did not give proper notice of residents’ room change . To investigate this allegation, on 03/18/2025, from 11:00 a.m. to 12:30 p.m., (LPA) interviewed the complainant and obtained documents related to the complaint. On 03/20/2025, LPA conducted the initial complaint visit from 9:30 a.m. to 2:15 p.m., during which (2) staff and (2) residents, including Resident #1 (R1), were interviewed, and R1’s records were reviewed. A subsequent visit was conducted on 08/07/2025, from 11:20 a.m. to 12:30 p.m., to conduct additional interviews. Information obtained during the investigation revealed that R1 was temporarily relocated to a shared room while renovations and repairs were completed in R1’s private room. Although it was noted that R1 has the power of attorney (POA) for financial and health decisions, R1 personally chose to remain in the shared room after the repairs were completed, exercising R1’s personal rights. Because this relocation was based on R1’s voluntary decision, and not an involuntary move imposed by facility staff, there was no requirement to issue formal notice of the room change. R1 confirmed to LPA that remaining in the shared room was R1’s personal choice and decision. Therefore, based on interviews, there is insufficient evidence to support the allegation. The allegation is deemed Unsubstantiated. Allegation #3: Staff did not communicate with resident's responsible party . To investigate this allegation, on 03/18/2025, from 11:00 a.m. to 12:30 p.m., (LPA) interviewed the complainant and obtained documents related to the complaint. On 03/20/2025, LPA conducted the initial complaint visit from 9:30 a.m. to 2:15 p.m., during which (2) staff and (2) residents, including Resident #1 (R1), were interviewed, and R1’s records were reviewed. LPA also reviewed email documentation provided by R1’s family, the complainant, and the Administrator. A subsequent visit was conducted on 08/07/2025, from 11:20 a.m. to 12:30 p.m., to conduct additional interviews. According to documentation reviewed, multiple email communications occurred between the Administrator and R1’s family. (Cont'd LIC9099C - page 2) The Administrator also informed R1 that the shared room could potentially be rented to another resident, and R1 acknowledged and accepted this possibility. Although it was noted that R1 has a (POA) for financial and health decisions, R1 independently chose to remain in the shared room, exercising R1’s personal rights. As such, there was no requirement for staff to obtain POA consent regarding this personal decision. Based on interviews and documentation, there is insufficient evidence to support the allegation. The allegation is deemed Unsubstantiated. Exit interview conducted, and copy of report provided to Administrator. agreement for a private room but was temporarily relocated to a shared room due to facility renovations. It was alleged that R1 was charged an additional $1,100 for the shared room. The investigation determined that the Administrator did not provide proper notice of the rent increase and that there was no valid justification for the additional charge. A review of R1’s admission agreement showed that the additional services listed in the rent increase notice were already included as basic services. LPA also reviewed the facility’s admission policy, which states that rent increase notices must be issued annually and must not include costs for additional services. Review of R1’s records and the rental increase notice confirmed that the notice included not only the rent increase amount but also charges for additional services. There was no updated or current reappraisal to verify significant changes in R1’s level of care that would justify an additional increase in rent. Based on interviews and record review, it was determined that the Licensee/Administrator did not follow the facility’s admission policies, admission agreement, or procedures regarding annual rent increases. Therefore, the allegation is SUBSTANTIATED. Exit interview conducted and copy of report provided to staff.