Complaint·March 30, 2026

This includes, but is not limited to, a prospective resident/resident who depends upon mechanical aids such as crutches, walkers, and wheelchairs. It also includes a prospective resident /resident who is unable, or likely to be unable, to respond physically or mentally to a sensory signal approved by the State Fire Marshal, or an oral instruction relating to fire or other dangers, and if unassisted, to take appropriate action relating to such danger". Medical assessment identified that R1 uses a four wheeled walker, has motor impairment/paralysis, and requires assistance with repositioning and transferring with stand-by-assistance. R1's living unit was located on the third (3rd) floor which is fire cleared for ambulatory residents only by the Fire Department. Varenna's fire clearance approval is, "VILLETTA BLDG-132 NON-AMB, INCLUDES 8 BEDRIDDEN. THIRD FL 72 AMB. CASIITAS #1 THRU #27, 54 NON-AMB. NO & SO BLDGS-64 NON-AMB." Per investigation, it was revealed that Upon R1's reappraisal on 2/18/26, by LVN Jennifer Haney, it was found that R1 was non-ambulatory per medical information obtained and reassessment On 2/19/26, LVN Jennifer Haney and RN Kari Miller contacted R1's responsible party to discuss the reappraisal of R1, and the non-ambulatory status. Responsible party was made aware of the third 3rd floor fire clearance of ambulatory only. Licensee/Administrator did not provide a 30-day written notice to R1 on moving apartments; Administrator had contact with R1's responsible party/family regarding the resident's change in condition, fire clearance approval of the facility's 3rd floor, and R1's discharge back to the facility to a non-ambulatory unit, etc. Administrator had contact on several dates by phone/texts, letter correspondence, emails, and in person, per the following: 2/20 Phone Conversation Re: Discharge and Ambulatory Status 2/20 EM with Copy of License; with additional phone follow up 2/22 Apartment showing at 2Pm scheduled for responsible party 2/23 Care Conference held in person 11am 2/23 EM follow up to Care Conference 2/24 EM with Residency Agreement; EM with Addendum, Phone call at 920am & 350pm 2/24 Texts with questions; in person meeting to “touch base” 2/25 EM with care pricing; EM with notice of care conference; texts to coordinate in person meeting at 12pm; Texts re: Move on 2/26; phone call at 550pm 2/26 In person check ins through the day 2/28 Text to check in Continued on LIC9099C... 3/2 Text Re: Apt vacated 3/3 In person meeting at 12pm 3/5 EM regarding lighting 3/17 Test re: meeting on 3/18 3/18 In person meeting at 1030am regarding Apt & internal waitlist Licensee did not issue 30-day notices to transfer units to an appropriately fire cleared room due to resident's change in condition. If a unit is available the resident may choose to transfer to the unit if agreed upon by all parties. Licensee does provide 30-day written notice of eviction when applicable, but Licensee/Administrator had not issued a 30-day notice of eviction at that time. The Administrator was offering the only available non-ambulatory unit for R1's transfer, covering cost of move into the unit, and some additional agreed upon items regarding the contract, the move, and the unit's amenities. R1 did return from the hospital and into the appropriately fire cleared unit, meeting their needs. Regarding allegations of "staff are inappropriately making resident move apartments" and "staff did not give resident's authorized representative a 30-day notice to move apartments", there was information to support violations had occurred. T he information obtained in this investigation didn't support that violations had occurred regarding alleged allegations. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations are UNFOUNDED. We have found that the complaint allegation(s) are/were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited during today’s visit. Exit interview was conducted with Administrator Douglas Blake.