complaint·October 21, 2025

9099C-1... Allegation: Due to lack of supervision, resident eloped from the facility. The allegation states resident (R1) eloped from the facility without staff knowledge on 7/12/25 , and the "bell" was not on the door. The Administrator stated that there were (2) nurses and a care aid present at the facility when (R1) eloped to the neighbor’s house on 7/12/25, and explained the incident was caught on camera. The administrator acknowledged that this incident was reported to the Department and a completed incident report was provided to the Department on 7/23/25, when the complaint was opened. Staff (S1) stated (R1’s) family member was outside in the car when (R1) exited the facility on 7/12/25. (S1) explained she and the family member circled the block and other neighbors assisted with searching for (5) minutes before locating (R1) in the neighbor's backyard, two houses over. (S1) stated she was serving dinner when (R1) was able to exit through the front door. A resident who was present on 7/12/2025 stated they recalled (R1) trying to often leave the facility through the front door. This resident confirmed the front door always has a “beep” sound or alert when it’s opened, but it must have been turned off when (R1) was able to leave that day. The resident stated staff was talking to a nurse who was visiting, and the alarm must have been turned back on after (R1) exited the care home. Interviews also concluded that (R1) tried to leave the facility previously on 7/2/25 but was unable to leave the property before staff were made ware and redirected resident back inside the care home. Based on information obtained, LPA finds this allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. *cont on 9099C-2.. 9099C-3... Regarding a higher level of care: The family member stated the administrator believes (R1) needs memory care after they eloped on 7/12/25, but (R1’s) Delirium was temporary and was due to a new medication that (R1) is no longer taking and (R1) is "fine". Documentation was reviewed by the department, including (R1’s) Monthly Progress Report that reflect (R1) becoming increasingly more confused, agitated, aggressive, needing more redirection, staying awake all night, and more difficult to redirect from February 2025 through July 2025. Additionally, the reasons for each hospitalization, on the following dates: June 24-25; July 2- 7; July 12, 2025, are due to the same behaviors. The administrator emailed LPA on July 16, 2025 regarding the elopement incident on July 12, 2025 which stated: Her daughter sent her out. She was extremely delirious and confused. She was at the facility that day. She also was on the phone with (R1’s) health care plan and spoke with the nurse and physician. The administrator also provided a letter to the department that she was “reassured that (R1) would be relocated to a different facility that would be more appropriate for (R1’s) psychosis” …and the administrator “had open communication with the agency who is in charge of (R1’s) placement and corresponded with their daughter as well and was told that every effort will be made to make sure (R1) would be relocated to a SNF or a memory care facility”. The administrator stated also in writing that "(R1’s) primary care and psychiatrists have been notified and kept informed” and “requests for medical evaluation or adjustments have been requested” and provided multiple text messages showing conversations between the administrator and (R1’s) placement agencies, health care staff and (R1's) family member. Staff and resident interviews corroborated that (R1) became increasingly confused, agitated, had trouble sleeping at night and was hallucinating until (R1) left the facility and was found in the neighbor's backyard. On July 16, 2025, the Department was provided with a copy of the 30-day eviction notice issued on July 15, 2025, and it was determined to contain all of the required elements to be a lawful notice; however, due to the resident not being given a 30 day notice until after being told the facility would not allow resident to return on/around July 12, 2025 , the Department finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. *cont on 9099C-2.. 9099C-2- Allegation: Unlawful eviction. The allegation states (R1’s) responsible person received a copy of a 30- day eviction letter on July 15, 2025, to be effective August 14, 2025, and the letter cited two reasons for the eviction 1- nonpayment of rent, and 2- (R1) needing a higher level of care due to delirium. Regarding the: rent: When moving into the facility, (R1) was participating in a funding program through a placement agency. As part of the contract, effective May 1, 2025, (R1) was to begin paying a monthly co-payment to the facility. Due to non-compliance with meeting monthly co-payments, an “End of Service” notice was issued by the placement agency on/around June 12, 2025 to terminate (R1’s) contract effective July 15, 2025. A representative from the placement agency stated to LPA in July that the decision to terminate the contract was appealed and an extension was granted for (R1) to be able to stay at the facility until August 15, 2025; however, generally when funding stops, it doesn’t matter if the contract has been extended. The administrator stated she referred (R1’s) family member to the specific program and on/around June 16-18, 2025, a sales representative from this program met with (R1’s) responsible person to sign paperwork so (R1) could be added to their program, once the placement agency ended their contract with (R1). Also at this time, on June 19, 2025, the facility had a change in ownership, and a new facility license was issued . Under the new license, the facility no longer had a contract with this new program. The representative at the placement agency stated to LPA on July 30, 2025, that (R1’s) responsible person needs to contact the new program for assistance in finding a facility that currently contracts with them. (R1’s) family member stated that the administrator referred (R1) to this specific new program as there are many facilities in the area that participate and claims she was not informed by the administrato r that she was not planning on signing a contract with them under the new facility license. Text messages from Thursday, July 17, 2025 document the Administrator telling the family member that “after reading the terms and conditions of the contract with ( ), I’ve decided not to contract with them “ and provided (2) local facility contacts that do contract with the company. The Administrator stated on July 30, 2025 that she has not received (R1’s) co-pay for July and confirmed that she refused to take (R1) back from the hospital before issuing the 30- day notice on July 15, 2025, due to their behaviors such as eloping and showing physical aggression. The administrator stated she had a 3-way call with (R1's) psychiatrist and family member, and the psychiatrist recommended the facility not take (R1) back until they were evaluated, observed and medications changed were effective. Records show (R1) was taken to the hospital on July 12, 2025 due to being “very confused, disoriented, aggressive and violent the prior days and nights” and interviews confirm (R1) did not return to the facility. *cont on 9099C-3..