complaint·July 3, 2024

Allegation: Facility director made inappropriate decisions for a resident to be placed at a different facility where the staff member later became a director. Throughout this investigation, LPA conducted interviews with facility staff, former staff and Power of Attorney (POA) representatives. Additionally, LPA conducted a review of resident files. According to interview with the POA representatives, the decision to relocate R1 was based on the need for a higher level of care which the assisted living could no longer provide. POA representatives further explained that R1 needed to be place in memory care based on current assessment of R1’s Behavior Therapist. The interviews further disclosed that while considering alternative placements at other facilities, the decision to move R1 to current facility was influenced by the recommendation of the former administrator, who had a positive relationship with R1. Additionally, it was clarified that the move was primarily driven by the need for memory care, which was not available at Chateau's at Rivers Edge at the time. Interview with current administrator confirmed that R1's relocation was necessary due to the requirement for memory care, which Chateau's did not offer at the time of the decision. Review of R1’s care notes revealed that on 12/19/23, R1’s behavior therapist had informed facility staff that R1 is not suitable for the community (Assisted Living) due to R1’s cognitive state. Based on that, further review revealed that on 12/20/23, POA representative for R1 contacted the facility informing them that POA will be putting in 30-day notice for R1. Based on all gathered information, the Department concluded that the allegation of inappropriate decision-making by the facility director regarding R1's relocation to a facility where they later became director is UNFOUNDED. The decision was justified by the resident's care needs and available placement needed at that time. {Page 2/4} Allegation: Staff coerced a dementia resident into signing documents. The investigation into the allegation that staff coerced a dementia resident (referred to as R1) into signing documents involved staff interviews and document reviews. According to an interview with staff, R1 demonstrated awareness of what they were signing at the time. Staff further noted the presence of a Notary Public during the signing of documents to assess R1's capacity to understand and consent to the content of the documents. Additionally, R1's accountant was present, providing further oversight. Review of Notary Public documents dated July 5, 2023, and October 4, 2023, confirmed R1 signed the documents in the Notary Public’s presence, verifying R1's identity and confirming that R1 executed the documents willingly and in their authorized capacity. Additionally, review of R1’s Physician Report (LIC 602A) dated January 23, 2023, indicated R1 was diagnosed with Mild Cognitive Impairment but retained the ability to follow instructions and communicate needs. Based on these findings, the Department concluded that the allegation of staff coercion of the dementia resident into signing documents was UNFOUNDED. The presence of a Notary Public, R1’s awareness during the signing process, and their ability to communicate needs supported the conclusion that the documents were executed voluntarily and in accordance with R1's capacity. {Page 3/4} Allegation: Staff billed a resident for two rooms at the same time. Throughout the investigation conducted by LPA, interviews and record reviews were conducted to address allegations concerning billing discrepancies for resident (R1). Review of R1's ledger from November 2019 to March 2024 revealed specific transactions. R1 was charged at the Independent Living unit for January 2023 on 12/21/22 and was credited partially for January 2023 on 1/23//23. Additionally, R1 was last charged at the Independent Living unit on 1/23/23, for the month of February 2023, but was credited the same amount immediately. Subsequently, on 1/23/23, charges appeared for R1 at the Assisted Living unit for the month of February 2023 and for part of January 2023. In an interview with the current Administrator, it was clarified that despite R1's belongings remaining in their Independent Living unit for nearly a year, R1 was not billed twice for occupancy. Based on the gathered information, the Department concluded that the allegation of staff billing resident for two rooms simultaneously was UNFOUNDED. The investigation confirmed that billing was handled appropriately, with no evidence supporting the claim of improper charges. Note that an unfounded finding means the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Marianne Richardson, Executive Director/Administrator, and a copy of this report was provided. {Page 4/4} This practice ensures that residents who require assistance are properly attended to during their mealtime and returned safely to their designated living area afterward. It was noted during interviews that Independent Living residents do not receive direct staff assistance as they are more independent, whereas Assisted Living residents receive necessary escorting. The investigation also referenced a documentation from R1’s Physician Report and Service Plan, which confirmed R1's need for extensive assistance and their inability to independently manage self-care due to cognitive impairment and physical limitations. Based on the gathered information, the Department concluded that the allegation that staff did not allow R1 to dine in the dining room of their choice was UNSUBSTANTIATED. The procedures in place, including escorting R1 and other residents when requested, were deemed appropriate given R1's care plan and safety needs. Note that an unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Marianne Richardson, Executive Director/Administrator, and a copy of this report was provided. {Page 2/2}