complaint·May 28, 2025

CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff did not reappraise resident when his condition changed , the following has been concluded. Resident R1 was assessed upon move-in in October 2023 and was then reassessed multiple times throughout the period of admission, with assessments reviewed for April 2024 after six months, then monthly after July 2024 once the resident was moved to the facility's memory care until R1's move-out in December. Gradual updates appear to reflect the evolution of R1's cognitive and behavioral abilities. Regarding the allegation that Staff did not provide resident's authorized person sufficient notice before changing his basic needs and services plan , the allegation is based on facility staff ordering the immediate implementation of a one-on-one caregiver starting on December 5, 2024. Per R1's admission agreement signed by all parties on September 27, 2023, the resident and their responsible party had agreed to a clause stating: " If you become a safety risk to yourself or to others during your residency, we have the right in our sole determination to obtain, at your expense, private duty personnel to provide supervision or assistance until you move from the Community or your safety is no longer at risk, and we will communicate that decision to someone on your behalf according to the Responsible Party and/or Emergency Contact information you agree to provide us. This communication will occur in advance of implementing a private duty caregiver, if reasonably possible, or soon after we have made the decision regarding your safety". Multiple incidents involving aggressive behavioral expression were reported to the responsible party as well as to the resident's primary care physician prior to the December 5 notification. Additionally, one-on-one supervision is not listed among the basic resident services for which a change in rate would require advance notice. Regarding the allegation that Staff kept resident isolated in his room , the following has been concluded: During both facility visits, licensing staff toured the memory care unit. During both visits, residents appeared free to ambulate, with no residents found to exhibit any signs of distress. Residents were observed relaxing in the unit's common area or in their respective bedrooms. Staff interviews evidenced that one of the recommended redirection strategies for some of R1's behavioral expression was to accompany the resident back to their unit to allow R1 to calm down as well as to avoid disrupting care for the other memory care residents. Interviews however did not provide sufficient evidence to corroborate that R1 was kept in their bedroom against their will. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Regarding the allegation that Staff did not provide adequate care or supervision for residents to prevent falls , the following has been concluded: R1 sustained multiple fall incidents during their admission at the facility. Multiple assessments reviewed show that the resident was identified as a fall risk upon admission. R1 sustained scalp lacerations as a result of a fall that occurred on a family outing in May 2024, as well as skin abrasions as a result of an unwitnessed fall in memory care. Two other falls occurred prior to R1's relocation to memory care and involved mobility in the facility's elevator. Such incidents did not recur after the resident moved to the unit located on the ground floor. Interviews and records reviewed did not evidence any failure to provide adequate care and supervision of a nature that would result in a fall. Regarding the allegation that Staff accepted a resident that required a higher level of care , the following has been concluded: Allegation was formulated regarding former resident R2, admitted on October 5, 2023 upon the basis of a pre-admission assessment dated September 29, 2023. Initial assessment was confirmed in the days following the move into the facility. R2 however declined rapidly and was reassessed to a higher needs profile on October 10, 2023, before being placed onto hospice care on October 12. R2 passed away with hospice present at bedside on October 14, 2023. However no elements of R2's assessment or physician report appear to indicate the resident would not have been appropriately placed at the facility or would have required continuous nursing care at the time of admission. R2 also appears to fit the criteria for acceptance and retention listed as Attachment D of their residency agreement. As a result of the evidence gathered during the investigation, all five allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.