complaint·November 25, 2025

On the allegation: Staff did not provide residents with a reappraisal. LPA De Leon reviewed the resident appraisal needs and service plan for R1. R1 had care plans done on 03/30/2022, 09/02/2022, 12/11/2023 and 09/16/2024. The plans for 2023 and 2024 were done on a different software program than prior plans completed. R1 suffered a fall with a fracture on 08/23/2024 which initiated the new service care plan on 09/16/2024 done by staff at the facility, R1 signed the plan, and it was emailed to R1’s Responsible party (RP) on 09/16/2024 for approval and signature. RP never received the email but in October R1’s fees increased, and the RP questioned why and how when there was no reappraisal, a new LIC 602A physicians report, or a meeting set up to discuss the changes. The facility said they had emailed her an updated service plan with the changes on 09/16/2024. The RP did sign the new service plan on 11/26/2024 and a new LIC 602A was done on 12/04/2024 to verify the changes being made to R1’s care fee increase. The facility did not follow the regulation for reappraisals, RP was not contacted, or a meeting arranged for R1’s change in condition and review of a new service plan before the facility billed for the increase therefore this allegation is Substantiated at this time. On the allegation: Staff did not report incidents to appropriate parties. LPA De Leon reviewed records for R1 which revealed several incidents of R1’s confusion were faxed and sent to R1’s doctor on 1/13/2024, 04/04/2024, 06/01/2024, 06/18/2024, 07/16/2024 and 11/11/2024 but not all the incidents were reported to R1’s RP’s based on interviews. RP’s said the communication with the facility was not good and when the RP’s reached out to the facility and left messages, no one from the facility replied. On 12/05/2024 R1 was moved into the memory care (MC) unit, when R1’s family went to visit the facility R1 could not be found and staff said R1 was now in MC. R1’s belongings were not with R1 in the MC unit and family took R1 back to R1’s apartment in the assisted living portion of the facility. The facility moved R1 without notification to the family into the MC unit due to R1’s increased confusion. The facility said R1 could stay in AL during the day for meals but needed to go to MC in the evening, R1’s RP’s didn’t agree to this arrangement or get an eviction notice that R1 could no longer live in the AL portion of the building and only learned of it through a family member that tried to visit. The RP’s said the facility had all updated information and phone numbers for the RP’s and made no contact to discuss the movement of R1 therefore this allegation is Substantiated at this time. Continued 9099-C On the allegation: Staff did not provide residents with 60-day notice prior to rate increase. LPA De Leon reviewed records which revealed the facility did a rent and care level fee increase to all residents on 11/01/2024 to be effective 01/01/2025. The facility mailed out the information to the residents and the RP’s on 11/01/2025. R1’s RP did not get anything from the facility for the increase effective 01/01/2025.R1’s RP’s decided with the lack of communication and R1 was not getting any more services for the increase R1 would move out before the new increase took effect. Resident 2 (R2) received a notice for increase of rent and care fees dated 11/14/2024 with an effective date of 01/01/2025 not a full 60-day notice therefore this allegation is deemed Substantiated at this time. Exit interview conducted, deficiencies issues, copy of report and appeal rights printed for Administrator. According to the Resident Service Plan dated 12/11/2023 R1 had facility doing medication management and observation of cognition and orientation. Incident Report submitted to the department on R1 for 08/23/2024 Caregiver heard a loud noise went to check and found R1 on the ground, 911 was called and R1 was transported to the hospital. According to the Hospital Discharge R1 had a fall on 08/23/2024, went to the ER and was diagnosed with a fracture to the upper extremity, face laceration with stitches, and discharged back to the community. R1’s LIC. 602 A dated 03/05/2024 R1 has MCI, exiting does not prevent a hazard, does not require additional monitoring while in the community and is Ambulatory. Staff 1 (S1) interview revealed S1 heard a loud noise and went to check R1 had a fall and staff called 911, and R1 was transferred to the hospital, it was not neglectful on the facility or the staff, it was an accidental un-witnessed fall. Based on the evidence this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report printed for Administrator.