complaint·July 29, 2025

Facility records and facility staff interviews found that R1 had previously resided in another of the licensee’s homes. While at the other home, R1 at times, exhibited exit seeking, agitation and medication refusals. R1 was transferred to this facility , where behaviors escalated slightly to include property destruction and aggression toward another resident. It was reported that R1 perceived R2 as using R1’s bathroom. In R1’s prior home, R1 had a private bathroom. A review of R1’s behavioral expressions plan (dated as “completed 5/19/25) found that the plan was not reviewed by an appropriately skilled professional and interviews found that staff did not implement the plan consistently. Therefore, while the licensee felt that R1 could possibly benefit from a specialty memory care program, the licensee violated R1’s personal right to be protected from involuntary transfer, discharge, or eviction. The refusal to allow R1’s return resulted in R1 remaining in the hospital longer than their condition required and the hospital used increased medication for behavioral control in the hospital setting. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. Report reviewed with . Copy of this report and appeal rights provided.