Complaint Investigation Report

It was reported that Resident #1 (R1) was moved to the memory care without documenting changes to the resident’s condition or notifying the residents responsible person. It was also mentioned that this transition was done without any prior notice or consent from the family.

Records reviewed confirmed R1 resided in the Assisted Living unit since 08/2020. Facility documentation showed that R1 began showing signs of cognitive decline, aggression and wandering behavior beginning in 01/2025 – 03/2025. Records reviewed revealed documentation of events leading up to R1’s move on 04/09/2025 to the memory care unit which is a secured unit with approved delayed egress exits. According to the ED and Health and Wellness Director it was unsafe for R1 to continue living in the AL due to R1’s increased confusion and exit seeking behavior. Staff interviews revealed that everything was communicated with R1, R1’s family and R1’s responsible person. Staff confirmed that R1 was able to speak english however was incoherent. Records reviewed and interviews conducted confirmed that R1’s family was aware of the move and R1’s responsible person signed the admission agreement (04/09/2025). Interview with R1’s responsible person revealed that they were aware of R1’s cognitive decline and the facility did communicate their observation of the change in R1’s condition. It was also confirmed that R1’s responsible person was aware of the necessary transfer and agreed to the transfer for R1’s safety.

Based on the above information gathered, there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations “Staff did not document changes to resident's condition and Staff did not obtain consent prior to moving resident into the memory care unit” are deemed unsubstantiated at this time.

Exit interview conducted and copy of report provided.