A family visitor, the Licensee representative, the Administrator, and obtained copies of pertinent documentation relevant to the investigation.

On the allegation, Staff did not provide resident 90-day notice of rent increase, it is the concern of the Reporting Party (RP) that the facility Licensee Representative (LR) did not provide Resident #1 (R1) the required 90-day notice of rent increase before increasing their rent. To investigate this complaint, LPA’s conducted in person interviews, telephonic interviews, file and record review, and obtained copies of pertinent documentation relevant to the investigation.

Interview with R1 revealed that in the beginning of May 2025 the facility owner informed them that they were going to increase the rent by $2,500 noting they were “too much trouble”. R1 stated they were not given the 90-day notice of the rent increase as required.

An interview with the facility’s Licensee Representative (LR) revealed that R1’s rate increase was based on a change in condition. It was noted that when R1 was admitted, they were ambulatory and required minimal assistance. Over time, R1 gained approximately 70 pounds, became non-ambulatory, and required one-on-one care and full assistance.

LR stated that they communicated regularly with R1’s Emergency Contact/Power of Attorney for Health Care and Living Will (EC) regarding R1’s condition and informed the EC that a rate increase would be necessary if the decline continued. A formal text message was reportedly sent to the EC regarding the increase; however, the exact date is unknown.

LR confirmed that R1 was not provided with a 90-day notice; however, the rate change was due to a change in condition, which the EC had been made aware of. It was also noted that no additional documentation was available. LR was unable to provide any documentation sent to R1 or to R1’s EC. LR further reported that they no longer have access to the text messages and therefore have no proof of communication.

Report continued on LIC 9099-C PAGE 3...

Additionally, a detailed explanation of the additional services to be provided at the new level of care, along with an accompanying itemization of the charges, was not provided or made available. R1 moved out on May 18, 2025.

During the 05/08/2025 visit, LPA's Cortez and Mosley observed the Facility Administrator documenting R1’s updated needs and service plan back dated to 05/01/2025.

Record review revealed that R1’s appraisal dated 04/10/2022 noted that R1 is alert, unable to ambulate independently, requires one-person assistance with a walker, is able to eat independently, and is dependent for showers and bathing. R1 has weak legs and arms, uses a walker with one-person assistance, and requires assistance getting up and out of a chair and bed. R1 is alert and oriented but non-ambulatory.

R1’s needs and service plan dated 03/06/2023 notes R1 as friendly and sociable, incontinent (using a urinal and needing assistance with toileting), and at risk for falls. R1’s needs and service plan dated 05/16/2024 reflects minimal changes, noting that R1 required assistance with scheduling medical appointments.

R1’s needs and service plan back dated to 05/01/2025, notes that R1’s PTSD continues to present challenges, resulting at times in manipulation of caregivers. R1 is a fall risk with an unstable gait, uses a CPAP for sleep, and is incontinent of bowels but uses urinals to urinate. R1 has COPD and uses an inhaler. R1 requires assistance during transfers and needs encouragement to use the toilet for bowel movements instead of relying on briefs. R1 is described as friendly but may become easily irritated if not receiving continuous attention from staff and does not adjust easily to changes in staff. R1 requires maximum assistance with all Activities of Daily Living (ADLs), including the use of a Hoyer lift for transfers.

Documentation revealed a rent increase notice dated 08/24/2023 indicating a rent increase from $4,700 to $5,000, effective 09/01/2023.

LPA attempted to contact EC on 02/09/2026 at 2:42 p.m. ,02/25/2026 at 11:10 a.m., 3/5/26 – 9:26 a.m., 3/20/26- 3:28 p.m.

The facility was unable to provide proof of written notice of the rate increase within two business days after initiating services at the new level of care, as required, and did not provide the required detailed explanation of the additional services or the accompanying itemization of charges. Based on information gathered during the course of the investigation there is sufficient evidence to support the allegation occurred.

During today's visit starting at 10:45 a.m. LPA and staff briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and the facility is in compliance with title 22 regulations.

On the allegation, Staff did not properly assist resident, resulting in resident falling and obtaining a fracture, it is the concern of the Reporting Party (RP) that a few years ago the exact date is unknown Resident #1 (R1) fell due to Staff #1 (S1) not properly assisting R1 resulting in a fracture. To investigate this complaint, LPA’s conducted in person interviews, telephonic interviews, file and record review, reviewed hospital records, hospice records and obtained copies of pertinent documentation relevant to the investigation.

Documentation revealed that R1’s physician report dated 02/26/2023 lists neuropathy deconditioned as their primary condition and non-ambulatory. Hospital records dated 05/10/2023 revealed that R1 was admitted to the hospital due to edema and cellulitis changes left leg and foot above knee, ulcer medial foot and ankle noted. The assessment plan noted that the cellulites developed erythema and an ulcer, R1 was seen by the wound RN and edema is better and cellulitis lateral leg and foot better. Incident report submitted to the department on 08/28/2023 reported that R1 was being assisted to their room by staff and began to become unbalanced and slowly rolled their ankle and were on the floor. 911 was called and R1 was transported to the hospital. Hospital records revealed that on 08/27/2023 R1 was admitted to the hospital due to 1. COPD exacerbation, 2. Trimalleolar fracture of right ankle, noting rolled ankle while ambulating with walker. Hospital records note that R1 refused to be discharged to a skilled nursing facility and was discharged with home health. Hospice records revealed that R1 was referred to hospice on 08/30/2023 and admitted on 08/31/2023. R1 was admitted with a primary diagnosis of chronic obstructive pulmonary disease with acute exacerbation and a list of secondary diagnoses of severe sepsis with septic shock, pneumonia, unspecified organism, essential primary hypertension, cellulitis of unspecified part of limb, gastro-esophageal reflux disease with esophagitis with bleeding, depression unspecified, spinal stenosis site unspecified, history of falling, heart failure unspecified, post-traumatic stress disorder unspecified. Report continued on LIC 9099-C PAGE 3...

Interview with S1 revealed that on the night of 08/27/2023 they were assisting R1 to their room from the living room. R1 was using their walker and S1 was directly behind R1 holding on to their pants as they were walking towards their room. R1 became unbalanced and dropped directly down, rolling on their ankle with all of their body weight. S1 immediately called 911 and noted they were unable to help R1 up due to their weight. R1 was transported to the hospital. At the time of the incident R1 was not required to use a gait belt nor were they actively using the gait belt at the time of the incident. Documentation supports that at the time of the incident a gait belt was not included in the care plan or included in a suggested care option.

Interview with R1 revealed that they are unfamiliar with the exact date of the incident when they rolled their ankle. They recall one night using their walker, S1 was behind them as they walked to the room. The walker slipped and they rolled their ankle but did not fall to the ground. They remembered feeling a pop and their ankle began throbbing. The staff called 911 and they were transported to the hospital. They believe S1 should have been holding on to them better to avoid the fall. They believe the staff should have been using the emergency belt for assistance.
Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the allegation of “Staff did not properly assist resident, resulting in resident falling and obtaining a fracture” is deemed UNSUBSTANTIATED at this time.

On the allegation, Staff did not elevate resident’s feet resulting in pressure sores, it is the concern of the Reporting Party (RP) that facility staff do not elevate R1’s feet resulting in pressure sores. To investigate this complaint, LPA’s conducted in person interviews, telephonic interviews, file and record review, reviewed hospital records, hospice records and obtained copies of pertinent documentation relevant to the investigation.

Documentation revealed that R1’s physician report dated 02/26/2023 lists neuropathy deconditioned as their primary condition and non-ambulatory. Hospital records dated 05/10/2023 revealed that R1 was admitted to the hospital due to edema and cellulitis changes left leg and foot above knee, ulcer medial foot and ankle noted. The assessment plan noted that the cellulites developed erythema and an ulcer, R1 was seen by the wound RN and edema is better and cellulitis lateral leg and foot better. Hospice records revealed that R1 was referred to hospice on 08/30/2023 and admitted on 08/31/2023. R1 was admitted with a primary ...

Report continued on LIC 9099-C PAGE 4...

diagnosis of chronic obstructive pulmonary disease with acute exacerbation and a list of secondary diagnoses of severe sepsis with septic shock, pneumonia, unspecified organism, essential primary hypertension, cellulitis of unspecified part of limb, gastro-esophageal reflux disease with esophagitis with bleeding, depression unspecified, spinal stenosis site unspecified, history of falling, heart failure unspecified, post-traumatic stress disorder unspecified. On 09/06/2023 it was noted that R1 has impaired skin integrity (redness) and is at risk of skin breakdown. On 10/04/2023 notes indicate that R1 had a left malleolus open sore, on 10/11/2023 it was noted that R1 had left outer malleolus sore and two (2) new pressure sores on right inner and outer malleolus. R1 was receiving continuous wound care. Records do not indicate that R1 was ordered to elevate their legs. Additionally, documentation notes that “however, even with proper treatment, a wound infection may occur.”

Interview with R1 revealed that the facility staff occasionally assisted them with elevating their legs, however on occasion staff did not assist them. Interviews with facility staff revealed that whenever the residents require assistance, they are there to help them. When residents require assistance with their legs being elevated, they will do so. Staff would encourage R1 to elevate their feet as recommended by hospice, however R1 will refuse or will choose not to. S1 stated “all they can do is encourage the residents and recommend it, we cannot force residents to comply”. It was further noted that R1 would elevate their legs most of the time. The facility purchased special pillows for R1 to support proper elevation and always made sure they were elevated when R1 allowed it.

Interviews with the Licensee representative revealed that staff consistently encouraged and elevated R1’s feet noting that they purchased equipment specifically for the purpose.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the allegation of “Staff did not elevate resident’s feet resulting in pressure sores” is deemed UNSUBSTANTIATED at this time.

On the allegation, Staff did not schedule a follow-up appointment for resident, it is the concern of the Reporting Party (RP) that facility staff failed to schedule a follow-up appointment for R1 after R1 fractured their leg. To investigate this complaint, LPA’s conducted in person interviews, telephonic interviews, file and record review, reviewed hospital records, hospice records and obtained copies of pertinent documentation relevant to the investigation.

Report continued on LIC 9099-C PAGE 5...

Interview with R1 revealed that they had an incident where they fractured their foot, were sent to the emergency room and they were instructed to schedule a follow up appointment. R1 stated that the Administrator #1 (A1) at the time did not schedule the follow-up appointment for them. R1 noted that the facility helps with arranging, scheduling and transporting them to appointments.

Interviews with staff revealed that the Administrator is typically the individual who assists residents with scheduling appointments. Staff may assist as needed; however, the Administrator is primarily responsible for that task.

An interview with the current Administrator #2 (A2) revealed that they have served as the Administrator of the facility since June 2024. During the time frame of the complaint, A2 was not employed at the facility and therefore could not speak to whether R1’s appointments were scheduled during that period. A2 stated that R1 is vocal and independent in managing their own appointments and ordering medications. Staff would occasionally assist R1 with scheduling appointments; however, this occurred only on rare occasions. It was noted that throughout 2023, R1 did not receive assistance from the facility with scheduling appointments, as documented in their care plan.

During facility visit 02/25/2026 at 11:28 a.m. LPA Mosley observed A2 assisting a family with scheduling a doctor’s appointment for a resident.

Documentation revealed that R1 was placed on hospice care immediately following their discharge from the hospital. R1 was admitted to the hospital on 08/27/2023. Hospice records revealed that R1 was referred to hospice on 08/30/2023 and admitted on 08/31/2023. R1’s care plan dated 03/06/2023 does not list assistance with scheduling appointments from the facility.

Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the allegation of “Staff did not schedule a follow-up appointment for resident,” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Report was reviewed and a copy was provided.