complaint·July 11, 2025

[Continuation from LIC 9099] Further review of facility records revealed between June 4, 2024, and June 25, 2024, there were several emails between R1 and Facility Management regarding issues R1 had with their current room, and they wanted to change rooms. On June 18, 2024, prior to the fall, R1 had sent an email stating their wheelchair broke and they were unable to walk due to a wound on the bottom of their foot, and they were told not to apply pressure on their foot to avoid an infection. R1’s email indicated a request to move to assisted living and paying for assisted living would not be a problem. Records and interviews revealed R1 was relocated to room 17F that is in a unit where more care is provided. On June 24, 2024, during the move, R1 sent an additional email notifying that they tested positive for COVID-19, and the fall they sustained on June 22, 2024, did not result in a fracture of their knee, but it was still very painful and required a brace. R1 requested staff to allow a close friend to enter both their apartments including 17F (Assisted Living) and unit 7b (Independent Living) to retrieve some of their belongings, while recovering in a Skilled Nursing Facility (SNF). Additionally, R1’s facility records revealed they signed and dated a contract at their time of admission on April 29, 2024. The contract included a clause regarding substitute apartments that states in the event a change of room is required for the safety of the residents directly related to state regulation and/or liability risk we may substitute your apartment to another to comply with any law or lawful order authorized of any authorized public official, or for any other reasonable purpose, as determined by us. We will make reasonable accommodation with respect to your preferences concerning your apartment. We will provide you with thirty (30) days’ written notice before substituting your apartment, unless you agree with the request, it is required to fill a vacant bed, or it is necessary due to an emergency. A facility record review dated June 18, 2024, revealed R1 resided in room 17F. However, on September 03, 2024, facility records revealed R1’s room was labeled O/C, and a review of the same facility record type dated September 30, 2024, disclosed R1’s room number was 17L and a new resident (R2) resided in 17F. An interview with the ED revealed R1 had given a verbal agreement to move their room while they were in the SNF. An email sent by R1, dated November 14, 2024, revealed R1 acknowledged being notified by the ED about the change in room while in the hospital, however stated they were not feeling well and could not remember at the time they had agreed at the time the complaint was filed. [Continued on LIC 9099C] *This is an amended versions of the original complaint delivered on July 11, 2025. [Continuation of LIC 9099C] It was also alleged that the Staff Management required R1 to take their contracted transportation agency and was told they were not permitted to use their own. An interview with ED disclosed that was a false statement and the facility has transportation available for residents in care if needed but they don’t have to use it. A facility record review revealed transportation (without an escort) is made available for specific activities but there is nothing in the contract that binds a resident to use the facility's transportation service. Interviews conducted with residents in care revealed staff had never required them to use the facility’s transportation services. Interview conducted with residents in care revealed staff had never required them to use the facility’s transportation services. Based on staff interviews and facility and resident records reviews the allegation was determined to be UNSUBSTANTIATED, an unsubstantiated finding means there was not a preponderance of evidence to prove the violation occurred. An exit interview was conducted with the ED and a copy of the report and Licensee Rights (LIC 9058) were provided. The signature below confirms receipt of the reports. *This is an amended version of the original report delivered on July 11, 2025.