Complaint Investigation Report

Review of resident records revealed that some residents received a written 90-day notice in May 2025 which stated that the basic rate of service would be increase effective September 1, 2025, which was a notice period of over 90 days. Interviews with residents revealed that the facility issued rate increases annually, usually on the anniversary of the resident’s move in date and advance notice was provided via written notice. Those interviews also revealed that the notice was generally provided at least 3 months prior to the rate increase taking effect. Interviews with staff revealed that rate increases were assessed on the anniversary date of the resident’s move-in, which was supported by information provided by residents. Interviews with staff responsible for handling resident billing revealed that residents were notified of the annual rate increase via written letter that was placed in their mailbox at the facility. Staff did not provide any evidence that the written notices were provided to residents less than 90 days prior to the notice taking effect.

Interviews with staff and facility management revealed that facility policy stated that staff would try to encourage residents to take their medications multiple times before noting the resident refusal, and would also try having a different staff member administer the medication or provide care. Interviews with staff supported this policy and provided evidence that staff would attempt to provide care or administer medications to R1 multiple times. Interviews with staff reported some difficulty with providing care and administering medications for R1 due to R1’s occasional resistance to care. Staff reported that R1 would often refuse medications and care if the medication or care was not provided immediately when R1 wanted to receive the care. R1 stated during interviews that staff confused R1’s medications, however, R1 did not provide clarification on the confusion or if R1 had ever received incorrect medications. Facility progress notes for R1 revealed that R1 stated that they were refusing because they no longer needed that medication. Interviews with staff and review of facility communication to R1’s physician revealed that R1 refused to take multiple medications and supplements, including a heart medication. These communications revealed that R1’s physician agreed with discontinuing other medications that R1 refused but did not agree to discontinue R1’s heart medication. R1’s medication administration records for July and August supported interview evidence that R1 often refused medications.