Complaint Investigation Report

Allegation #1: Facility staff are retaining residents that require a higher level of care.

It is alleged that the facility staff are retaining residents who require a higher level of care. Reports suggest that the facility allows residents who should not be there to remain at the facility. It has been noted that residents with Neurocognitive Disorder (NCD) wander around the facility, often not knowing where they are. No additional details regarding this allegation have been provided.

On January 31, 2026, between 08:40 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #7 (S1-S7). Seven (7) out of seven (7) staff members could not validate this claim. (S1) confirmed that there are no residents currently retained in the facility who require a higher level of care. The facility is licensed to provide assisted living and memory care. (S1) stated that the facility collaborates with home health and hospice agencies and is licensed to accommodate 25 hospice residents, but currently only 10 are receiving care. To ensure the facility does not retain a resident who needs a higher level of care, they typically follow these steps: monitor changes in condition, review facility admission and retention criteria, engage healthcare professionals, communicate with residents and their families, and document everything. (S1) further explained that these steps are performed when the resident has been hospitalized for several days. (S2-S7) verified that there are no residents that are being retained with restricted or prohibited health conditions at the facility.

On January 31, 2026, between 09:00 AM and 11:59 AM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of ten (10) could not validate this claim. All residents are unaware of any resident being retained at the facility that requires a higher level of care.

During the visit on January 31, 2026, an inspection included observing residents in rooms #115, #118, #120, #132, #137, #143, #208, #226, and #252, in the assisted living and memory care units. The Department did not observe any residents who required higher acuity of care.

A review of the facility Resident Roster (dated: 01/31/26) and Personnel Roster (dated 01/31/26) along with personnel training requirements. Upon further review of the two random resident physicians' report, LIC 602A, it was determined that the residents do not require a higher level of acuity in care.

Due to a lack of sufficient information, including the absence of names of residents or demonstrative evidence, there is insufficient evidence to support the allegation mentioned above.