Creston Village Assisted Living and Memory Care.

On March 3, 2026 at 9:00am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a case management - other visit to the facility. LPA met with Administrator Adam Bramwell and explained the purpose of the visit. On February 27, 2026 Administrator notified LPA via email that an audit conducted that day discovered missing medications. On March 2, 2026 LPA interviewed the Administrator and Wellness Director over the the phone for further details. During today's visit LPA gathered documentation, conducted interviews and toured select areas of the facility. No deficiencies issued during today's visit. LPA will return at a later date to conclude the investigation and issue citations. Exit interview conducted, report signed, and report delivered to the Administrator.

On 1/6/2026, at 9:15am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced to this facility to conduct the annual inspection. LPA met with facility Administrator Adam Bramwell, announced who he is and the reason for the visit. At approximately 10:00am, Administrator and LPA conducted a full facility walk through and tour. This is a two story facility with a section dedicated to memory care on the first floor. The facility is square in shape with an outdoor courtyard in the center and one wing off to the south-east. LPA noted upon entering the main entry a lobby with reception desk to the left; an entrance to the large communal dining room across from the main entry doors; and a resident snack bar, the main kitchen, staff laundry room, staff room, maintenance room and employee entrance are to the right. The communal dining room has a smaller banquet room for small private events. On the first floor past the reception desk are administrative offices, a gathering/activity space (with piano, fishtank, and self-contained fireplace for residents and visitors to enjoy), 32 resident rooms with en-suite bathrooms, medication room, a dedicated activity room, public restrooms, laundry room and maintenance/housekeeping closets locked for resident safety. The memory care unit is separated by coded egress doors with an additional 15 resident rooms that have en-suite bathrooms, multiple activity rooms, a dining room and a fenced outdoor area with tables and shade for residents and visitors. LPA noted meals are delivered from the main kitchen to the memory care unit and served from the memory care kitchen. On the second floor there are 49 resident rooms with en-suite bathrooms, physical therapy room, laundry room, snack bar area with seating, beauty shop, and a TV/activity space. LPA inspected a sample number of resident rooms and noted that the rooms had working lights, ample storage, working appliances and non-skid surfaces in the showers. LPA noted an emergency evacuation chair located at the top of the five stairwells and the elevator was serviced on 12/24/2024. (Continued on LIC809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The facility exterior has a walking path around the entirety of the facility and an outdoor courtyard in the middle of the facility which also has tables and shade. There is a designated smoking area just outside the west side of the dining-room. The facility has wired/battery operated dual smoke/carbon monoxide detectors in each resident room and smoke detectors in the hallways tested by Alpha Fire on 8/6/2025. LPA observed fire extinguishers throughout the facility tagged current and in the green compression range, being serviced during todays visit. LPA tested facility hot water at various locations measuring between 109 & 112*(f), within regulation temperatures 105*-120* (f). LPA noted that the facility has no obstructions in hallways, doorways or exits. Medications are locked in medication carts. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication and Destruction Records. Administrator and LPA conducted a partial review of the facility annual CARE tools module. LPA will need to return to finish the annual. At this time no deficiencies are being cited. Exit interview, report read, and report provided to the Administrator.

obvious neglect of incontinence care. On 01/21/2025 LPA Jeffries conducted interviews with Staff 1 – 4 (S1, S2, S4, S4) all stated that R1 has incontinence issued with “digging” and are always addressed by staff when observed and as needed. LPA reviewed facility care plan for R1 that shows two showers per week. At this time there is not enough evidence to support the allegations of. “Staff do not ensure that resident’s incontinence needs are being met.” And “Staff do not ensure that residents are assisted with bathing. “ both are unsubstantiated at this time. As to the allegations of, “Staff do not respond to residents call for assistance.” and “Staff are not assisting residents with medications in a timely manner. “It was alleged that R2 was yelling “Help me” and no staff responded. It was discovered through documentation, observations, and interviews that on 11/21/2024 LPA conducted a physical tour of facility and observed R2 in their room. R2 was vocal during the LPA observation stating “lord help me” LPA observed S4 attending to R2’s needs. On 11/21/2024 LPA Jeffries conducted an interview with S4 who stated that R2 baseline is continually requesting staff assistance by calling out or yelling for staff. S4 stated that Staff check on all residents, including R2 approximately every 15 minutes or less. Interviews on 11/21/2022 with S1, S2, S3, and S4 all stated that residents are continually checked for any changes in conditions of residents. All stated they have high confidence in all staff and no staff are neglecting residents needs. On 11/21/2024 LPA Jeffries attempted to interview R1, R2, R3, and R4 all stated they feel safe in facility, however none answered screening questions when LPA was checking cognitive understanding. On 11/21/2024 LPA Jeffries reviewed R1 and R2’s Physicians reports, Centrally Stored Medication Records (CDMR), and Medication Administration Records (MAR)and found no abnormalities. At this time there is not enough evidence to support the allegations of, “Staff do not respond to residents call for assistance.” and “Staff are not assisting residents with medications in a timely manner. “ and are both unsubstantiated at this time. CONTINUED on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 As to the allegation of, “Staff did not respond to resident's fall.” It was alleged that approximately between October 28 through November 3 of 2024 an unknown resident had fallen, and no staff assisted the resident. On 11/20/2024, 11/21/2024, and 11/23/2024 LPA Jeffries attempted to contact the reporting party (RP) by phone with no answered. As of 03/10/2025 there has been to return call from RP. On 11/21/2024 and 11/27/2024 LPA Jeffries reviewed facility serious incident reports (SIRs) which reviled the following: On 10/25/2024 a resident fell in their room, pressed pendant and staff address fall; accordingly, there was no other recorded resident fall in the time period of the alleged fall and there were no subsequent reports of resident injury within that time frame of the alleged fall. At this time there is not enough evidence to support the allegation of, “Staff did not respond to resident's fall.” and is unsubstantiated at this time. Exit interview, report read, and report provided.

At 9:00am on 01/23/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facilities annual inspection. LPA met with facility Administrator, Adam Bramwell, announced who he is and the reason for the visit. Additionally, LPA will issue final findings to a separate complaint on a separate report on this date. At 12:30pm, Administrator and LPA conducted a full facility walk through and tour. LPA noted that the facility has a 130 person capacity and has a current census of 96. The facility exterior has walking path around the entirety of the facility and a covered main entrance. There is a designated smoking area just out side the dining-room entrance that has a covered gazebo on the side of the facility. LPA noted that the memory care unit of 15 resident room with on suite bathrooms located in the back of the facility and has a fenced outdoor area that is also in the back of the facility, which has tables and umbrellas for shade. LPA noted that the facility has a outdoor courtyard in the middle of the facility which also has tables and umbrellas for shade. LPA did not observe any issues or violations on the outside areas of the facility. LAP noted that this facility is two stories and has 4 distinct wings. On the first floor there area 35 resident rooms with on suite bathrooms, On the second floor there are 50 resident rooms with on suite bathrooms. LPA inspected a sample of rooms rooms and noted that all rooms had working lights, ample storage, working appliances and non-skid surfaces in the showers. LPA observed that there is a medication room, physical therapy room, laundry room, snack bar area with seating, beauty shop, and an tv activity room on the second floor. LPA noted that all three stair wells had emergency fire chair at the top of the stairwells. LPA noted that the dining room, kitchen, laundry room, staff room, maintenance room and employee entrance on the first floor on the north side of the building. LPA noted that the front entrance has offices and reception desk, and a lounging room for residents. LPA note that there are assorted offices on both the first floor and second floor. LPA noted that there were fire extinguishers placed all throughout the facility, all fire extinguishers that were inspected were in the prime and charged in the green. LPA observed working carbon monoxide detectors through out the facility. CONTINUED on LIC809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA noted that all walkways and entrances were free and clear of debit. At 9:40am Administrator and LPA conducted a full review of the facility annuals control tools module. LPA noted that no citations or violations as result of the annual care tool modules review. LPA noted that the annual facility inspection resulted in no violations or citations at this time. Exit interview, report read, and report provided.

In an interview with R1 on 09/16/2024 by LPA Jeffries, R1 did not recall staff restraining R1 at any time. R1 stated that they have lived at the facility “for years”. R1 stated that they feel safe with staff and care at this facility. On 01/22/2025, LPA conducted a phone interview with R1’s Responsible party (F1). F1 stated that R1, had an undiagnosed stroke sometime in R1’s past (as told by R1’s Physician, Dr. Bettencourt) which resulted in R1’s right hand being closed. F1 stated that facility staff attempted to cut R1’s fingernails on the right hand but did not force R1. On 09/16/2024, LPA Jeffries conducted interviews with S4, S5, and S6, and all staff stated that they have never participated or have witnessed a restraint of any resident at this facility. On 09/16/2024, LPA Jeffries conducted interviews with R2, R3, R4, and R5, all stated that they have never been or seen any type of resident physical restraint at this facility. All four Residents stated that they feel safe in this facility and all staff treat them with dignity. LPA conducted a record review of incident reports for the month of September of 2024 and found no account of reported restraints or staff to resident interventions. At this time there is not enough evidence to support the allegation of, “Staff inappropriately restrained resident.” and is unsubstantiated at this time. As to the allegation of, “Staff are not safeguarding resident’s personal belongings.” It was alleged that R1 had lost two sets of R1’s dentures. Additionally, a toothbrush that was dirty and black was found. It was discovered through interviews that on 09/16/2024, LPA Jeffries conducted interview with Facility Administrator, Adam Bramwell, who stated that R1’s Responsible Person (F1) brought to the facilities attention that R1’s dentures were missing. Administrator stated that they instructed staff to conduct a through search in memory care unit for missing dentures, but they were not found. On 01/22/2025 LPA interviewed F1, who stated that they were aware of one set of dentures being missing, they reported to the facility and the facility conducted a search but did not find the dentures. F1 also stated that R1 has had a history of hiding their dentures and sometimes throwing them into the trash and did not dismiss this possibility in this instance. F1 stated that they facility followed through in their responsibility and due diligence to locate the missing dentures. On 09/16/2024, LPA Jeffries interviewed S1, S2, S4, and S5, all had been instructed to search for missing dentures which were not found. Additionally, S1, S2, S4, and S5 were all shown a picture of the dirty black toothbrush, and all stated they had never seen that toothbrush before and would have collected it and notified supervisors if they had seen a toothbrush in that condition. CONTINUED on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 On 09/16/2024, LPA Jeffries noted on an inspection of R1’s room one clean toothbrush that appeared to show normal use which was the brand of Oral B, two unused new toothbrushes that were the brand of Colgate, all had R1’s name written on the handle of the toothbrushes, however the dirty black toothbrush, was not a brand name toothbrush nor did it have R1’s name on the handle. At this time there is not enough evidence to substantiate the allegation of, “Staff are not safeguarding resident’s personal belongings.” and is unsubstantiated at this time. As to the allegation of, “Staff are not ensuring resident is showered.” It was alleged that R1 was not getting showers. It was discovered through interviews and documentation that on 09/16/2024, LPA Jeffries interviewed R1, who stated, “Staff take good care of me, I like the staff.” and that their (R1) needs were always met and have never had an issue with care, including bathing and incontinence. On 09/16/2024, LPA Jeffries conducted interviews with S1 and S2 who stated that showers for R1 are offered 4 times per week, and often R1 would refuse showers. S1 and S2 stated that they would let supervisor know and note in the shower refusal log when R1 would refuse shower. S1 and S2 stated that R1 would normally be showered one to two time per week on average. LPA Jeffries reviewed facility documents labeled “Shower Refusal” for R1, which shows that R1 had refused showers on 10 occasions during the time period of August 15 through September 15th of 2024 which is a refusal of 10 of 20 shower days. On 01/22/2025 LPA conducted an interview with F1, who stated that the facility will call F1 who is R1’s responsible party and notify F1 when R1 has a shower refusal. F1 stated the facility will call but not always the same day. At this time there is not enough evidence to substantiate the allegation of, “Staff are not ensuring resident is showered.” and is unsubstantiated at this time. As to the allegation of, “Staff left resident in soiled diapers for extended period of time.” It was alleged that, facility are leaving R1 in soiled diapers for a long time. It was discovered through interviews on 09/16/2024, LPA Jeffries interviewed R1, who stated, “Staff take good care of me, I like the staff.” and that their (R1) needs were met and have never had an issue with care, including bathing and incontinence. On 09/16/2024 LPA Jeffries conducted an interview with S1, S2, S4, and S5, who all stated that residents are monitored throughout the day for incontinence and incontinence is always addressed when needed. On 01/22/2025, LPA Jeffries conducted an interview with F1 who stated, the facility dose a good job with R1’s incontinence and had never had an issue or problem with the facility addressing R1’s incontinence in a timely manner. At this time there is not enough evidence to support the allegation of, “Staff left resident in soiled diapers for extended period of time.” and is unsubstantiated at this time. Exit interview, report read, and report provided.

S1 stated that R1 denied any sexual acts that have happened while in the facility, additionally, there are no male staff currently or recently assigned to the memory care unit where R1 resides. S1 stated that staff that work with R1 were instructed to monitor who enters or exits R1’s room, staff have not observed any male enter R1’s room. S1 stated that R1 exhibits overt sexual language when R1 is upset which has been a consist behavior from the beginning of R1’s residing at this facility, according to S1 interview on 11/02/2024. On 11/02/2023, LPA interviewed Staff 3-10, (S3-S10), all stated that R1 typically exhibits explicit profanity as a normal behavior for R1 and has refused care giving assistance when upset.. On 11/02/2024, LPA, S1 and facility Administrator conducted an interview with S2. S2 stated that they had a conversation with a staff member about R1 but did not provide any other details about R1 other then what R1 stated, “He raped me”. Based on interviews, observations and documentation, at this time there is not enough evidence to support the allegation of, “Resident sexually abused while in care.” and is unsubstantiated at this time. As to the allegation of, “Resident sustained unexplained bruising while in care.” It was alleged that Resident had bruises all over their body and look like finger bruises. It was discovered through interviews, observations, and documentation that, on 11/02/2024, LPA Jeffries attempted to interview R1, and R1 was not responsive to basic screening questions. LPA did observe one red bruise on the left forearm of R1 that was approximately 2” with round shape and no indication in the shape that could determine how the bruise may have occurred. On 11/02/2023 LPA Jeffries reviewed R1’s LIC602 (Physicians Report) that indicated a primary diagnosis of Edema. On 11/02/2023, LPA interviewed Staff 3-10, (S3-S10), all stated that R1 typically exhibits explicit profanity as a normal behavior for R1 and has refused care giving assistance when upset. S3-10 stated they have not observed any other bruising on R1’s body other than the left forearm bruise. Based on interviews, observations, and documentation there is not enough evidence to support the allegation of, “Resident sustained unexplained bruising while in care.” and is unsubstantiated at this time. As to the allegation of, “Staff do not ensure that residents take medication as prescribed.” and, “Staff do not ensure residents’ incontinence needs are met.” It was alleged that staff do not properly administer medication to R2 and R2 “stashed” medication in their drawer as well as R2 left in soiled briefs for extended periods. On 11/02/2023 LPA Jeffries conducted an interview with R2, R2 stated that they have always take medication when provided by staff. R2 denied hiding or stashing medications at any time. R2 stated that staff do a good job with incontinence needs and medications including prescribed ointments as need. LPA observation during interview, noted that no medications or ointments were in R2’s drawers. On 11/02/2024 LPA Jeffries reviewed R2’s LIC602 (Physicians Report) which indicated UTI as a secondary diagnosis. CONTINUED on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA also observed Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR)for R2 and did not find any missed medications. LPA reviewed Physician notes on facility visit of R2 on 08/22/2023 and 09/05/2023 both listing frequent UTI’s. On 11/03/2023, LPA reviewed facility serious incident reports (SIR) and did not find any SIR’s with R2 as the subject. LPA interviewed S3-10, who all stated that medications are always given as prescribed to their knowledge. S3-S10 all stated that all residents are always monitored for incontinence and cared for when incontinence care is needed. Based on interviews, observation, and documentation, there is not enough evidence to support the allegation of, “Staff do not ensure that residents take medication as prescribed.” and “Staff do not ensure residents’ incontinence needs are met.” are both unsubstantiated at this time. As to the allegation of, “Staff do not assist residents with showering.” It was alleged that R2 and R3 were not regularly showered. It was discovered through documentation and interviews that on 11/02/2023 LPA Jeffries reviewed Admissions agreements, Level of Care Plans, Shower Schedules/Refusal documents for R2 and R3. Both R2 and R3 were assessed at the highest level of care (facility Level 6) provided by the facility. On 11/02/2023, LPA interviewed R2, who stated that the staff take care of bathing needs daily, most often while in bed. R2 stated that staff did a good job of keeping R2 clean. On 11/02/2023, LPA Jeffries conducted and interview with R3 who stated that the facility helps with shower daily. LPA observed and noted during the interview that R3’s room was clean and did not have any apparent emanating orders. LPA noted that R3’s facility care plan outlines daily shower as confirmed by R3. On 11/02/2023, LPA Jeffries conducted interviews of S3-S10 who all stated, stated that all residents are monitored at all times for incontinence and cared for when incontinence care is needed. Based on interviews, documentation, and observations, at this time there is not enough evidence to support the allegation of, “Staff do not assist residents with showering”. and is unsubstantiated at this time. As to the allegation of, “Staff do not ensure that residents’ dietary needs are met.” It was alleged that staff “throw” food in front of R2, then leave. It was discovered through documentation and interviews that on 11/02/2023, LPA Jeffries interviewed R2. R2 stated that they have never had any issues with food service at this facility. R2 denied that staff threw or left food for R2 at any time. On 11/02/2023, LPA conducted interviews with S3-S10, all staff were aware that R2 required meals to be set up for R2. All denied throwing or leaving food for R2 that R2 was not able to consume. On 11/02/2023 LPA reviewed R2’s LIC602 (Physicians Report) which indicated that R2 is able to feed self, with “set up assistance.” At this time there is not enough evidence to support the allegation of, “Staff do not ensure that residents’ dietary needs are met.” And is unsubstantiated at this time. CONTINUED on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 As to the allegations of, “Staff do not provide residents with a housekeeping service.”, “Staff do not ensure that the facility is maintained sanitary.”; and “Staff engaging in food preparation are not observing sanitation practices.” It was alleged that; Kitchen staff do not wash hands when preparing meals for residents. And dining mats are not sanitary. And R3’s room smells of urine and is not cleaned. It was discovered through interviews, photographs, documentation, and observations that, on 11/02/2024 LPA Jeffries conducted an interview with R3. R3 stated that the facility helps with shower daily. LPA observed and noted during the interview that R3’s room was clean and did not have any apparent emanating orders. On 11/02/2023, LPA Jeffries interviewed S3-S10 who all confirmed R3 had incontinence behaviors that are continuously being addressed by staff and housekeeping staff. S3-S10 all confirmed that housekeeping staff will address any cleaning problems as needed on top of their normally schedule cleaning tasks. On 11/02/2023 LPA reviewed facility housekeeping schedule and noted no gaps or call offs in house keeping schedule. On 11/02/2023 LPA Jeffries observed kitchen staff preparing lunch, all were wearing black gloves. LPA interviewed Kitchen Staff S13 who stated that all food preparation is conducted with gloves for hygiene and sanitary reasons. LPA observed and photographed dining place mats and noted all were clean and free of stain and foods. On 04/09/2024, at approximately 10:50am, Administrator Adam Bramwell and LPA Jeffries conducted a visual inspection of all 14 bathrooms in the memory care unit. LPA photographed and noted that 13 of 14 bathrooms were clean and in good working order. LPA noted that the one bathroom in question was cleaned, however the floor was sticky. This was discovered to not be a sanitation issue but a floor material issue that is being addressed by the administrator. On 04/09/2024, LPA Jeffries interviewed Memory Care Staff 5, 11, and 12 (S5, S11, and S12), who all stated that their job duties included cleaning restrooms as needed. S5, S11 and S12 all stated that they knew they could call housekeeping on the radio if there was a need to have a residents restroom cleaned due to an immediate need. LPA noted that there was no evidence on this visit to indicated that staff do not ensure resident’s restrooms are cleaned and sanitized. LPA reviewed documentation (Job Description) of staff duties of Pegasus Senior Living for the position of Care Partner that included but not limited to, “Maintains clean, neat, comfortable, safe environment for Residents, Staff and visitors, including housekeeping services for Residents.” Which S5, S11, and S12 all acknowledged in interviews on 04/09/2024. At this time, there is not enough evidence to substantiate the allegations of, “Staff do not provide residents with a housekeeping service.” “Staff engaging in food preparation are not observing sanitation practices.” and “Staff do not ensure that the facility is maintained sanitary.” and all are unsubstantiated at this time. Exit interview, report read, and report provided.

On 04/09/2024, LPA Jeffries interviewed Memory Care Staff 1, 2, and 3 (S1, S2, and S3). S1-3 all stated that their job duties included cleaning restrooms as needed. S1-3 all stated that they knew they could call housekeeping on the radio if there was a need to have a residents restroom cleaned due to an immediate need. LPA noted that there was no evidence on this visit to indicated that staff do not ensure resident’s restrooms are cleaned and sanitized. LPA reviewed documentation (Job Description) of staff duties of Pegasus Senior Living for the position of Care Partner that included but not limited to, “Maintains clean, neat, comfortable, safe environment for Residents, Staff and visitors, including housekeeping services for Residents.” Which S1-3 all acknowledged in interviews on 04/09/2024. At this time, there is not enough evidence to substantiate the allegation of, “Staff do not ensure resident’s restrooms are clean and sanitized.” And is unsubstantiated at this time. Exit interview, report read, and report provided.

At 9:57am on 02/15/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Interim Administrator, Adam Bramwell announced who he is and the reason for the visit. Administrator and LPA conducted a full facility walk through and tour. LPA noted that the facility has a 130 person capacity and has a current census of 74. The facility exterior has walking path around the entirety of the facility and a covered main entrance. There is a designated smoking area just out side the dining-room entrance that has a covered gazebo on the side of the facility. LPA noted that the memory care unit of 15 resident room with on suite bathrooms located in the back of the facility and has a fenced outdoor area that is also in the back of the facility, which has tables and umbrellas for shade. LPA noted that the facility has a outdoor courtyard in the middle of the facility which also has tables and umbrellas for shade. LPA did not observe any issues or violations on the outside areas of the facility. LAP noted that this facility is two stories, it has 4 wings. On the first floor there area 35 resident rooms with on suite bathrooms, On the second floor there are 50 resident rooms with on suite bathrooms. LPA entered a sample of rooms (10) rooms and noted that all rooms had working lights, ample storage, working appliances and non-skid mats in the showers. LPA observed that there is a medication room, physical therapy room, laundry room, snack bar area with seating, beauty shop, and an tv activity room on the second floor. LPA noted that all three stair wells had emergency fire chair at the top of the stairwells. LPA noted that the dining room, kitchen, laundry room, staff room, maintenance room and employee entrance on the first floor on the north side of the building. LPA noted that the front entrance has offices and reception desk, and a lounging room for residents. LPA note that there are assorted offices on both the first floor and second floor. LPA noted that there were fire extinguishers placed all throughout the facility, all prime and charged in the green. LPA observed working carbon monoxide detectors through out the facilty. LPA noted that all walkways and entrances were free and clear of debit. Administrator and LPA conducted a full tool module review and no violations of or citations were noted. One Technical Violation was issued on late Administrator Certificate which will be corrected on May 22, 2024. Exit interview, report read, no violations, and report provided.

However, there is no indication on the residents billing statement that the newly added service will be prorated, which caused a temporary over billing when services are added during the billing cycle. Additionally, the residents bill has an overdue amount in three time frame sections at the bottom of the billing form that indicates the amount of time there is with a past due amount, which can be inaccurate based on the initial monthly overcharging amount before prorated and credited amount. The facility overcharges the new service without explanation of how it gets resolved, and because there is no explanation the resident receives a bill for the wrong amount for that month and the bill reflects a past due amount, placing an inaccurate past due amount on the residents bill at the bottom of the bill. Based on the initial monthly overcharge the allegation of, “Facility overcharging residents in care.” Is substantiated at this time. The same type of allegation was addressed and cited on Case# 29-AS-20221109110234 during the same time period investigated, subsequently there will be no LIC9099-D for this report, see referenced case report for deficiency and plan of correction.. Exit interview, report read, appeal rights and report provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 However, based on documentation of LIC602 (Physicians Report) showing that R1 had full capabilities of self-care and medication management, and the POA only covered health related oversight, the facility acted in due diligence according to releasing R1’s financial information to F1 at the time this complaint was filed. Based on documentation and interviews the allegation of, “Staff are not providing an authorized representative access to a resident’s personal records.” is unsubstantiated at this time. As to the allegation of, “Staff are not following the admission agreement.” It was alleged that the facility was not notifying R1’s responsible party for billing and care assessment and changes in level of care billing and dietary assessments. On 03/10/2023 and 03/20/2023, LPA reviewed documentation including LIC602A (8/11) Physicians Report, singed and dated 09/15/2022, Facilities semi annual evaluations signed and dated 12/13/2022, 01/06/2023, and 03/15/2023, and Facilities dietary orientation form dated 10/03/2022. R1’s LIC602A (8/11) (Physicians Report) that indicated that R1 had full capabilities of self-care and medication management, signed on 09/15/2022. It was discovered through interviews of F1 on 02/27/2023, that R1 moved into the facility on R1’s own volition, and there was a Power of Attorney (POA) record for R1 identifying F1 and F2 as full health care POA’s for R1 dated 06/04/2019. The facilities first semi annual evaluation report was facilitated to F1 by phone conference and email follow up for Power of Attorney (F1). The facilities second semi annual evaluation report was signed by R1 and in accordance with R1’s LIC602A (Physicians Report) also signed by R1 on 01/06/2023, and R1’s third semi annual evaluation was emailed to F1 on 03/15/2023. LPA interviewed S1 on 03/02/2023 and indicated that the facility was working to provide F1 paperwork for financial records upon the authorization of R1. At the time of the interview on 03/02/2023 F1 had access from the facility to R1’s records. However, based on documentation of LIC602 (Physicians Report) showing that R1 had full capabilities of self-care and medication management. Based on documentation, interviews, and email confirmations there is not enough evidence at this time to support the allegation of “Staff are not following the admissions agreement.” and is unsubstantiated at this time. CONTINUED on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 As to the allegation of, “Staff are not properly trained.” It was alleged that R1 was not properly assessed for dietary restrictions based on R1’s LIC602A (8/11) which indicated that R1 had a special diet of, “Low concentrated sweets, regular.” This information was also in resident file and additionally located in the kitchen available for review to all kitchen staff and Food Service Director (S7). On 11/17/2022, S7 provided LPA with a tour of the kitchen and resident dietary screening procedure. LPA observed R1’s admissions “Dietary Order/Information” dated 10/03/2022 indicating LCS (Low Concentrated Sweets) diet. LPA noted that the residents dietary oversight procedure was simple to follow and understandable. LPA reviewed the following documentation: “Crandell Corporate Dietitians Assisted Living Quarterly Audit” dated 09/15/2022, conducted by Registered Dietitian Jo Bergstrom with certification from Commission on Dietetic Registration (#708490) expiring 08/31/2026 for executive oversight and regulation requirements. The kitchen is operated on a daily basis by S7 who has 8 years of Executive Chief experience and Associates of Science Degree from California Culinary Academy - Food Services (June 1997). Additionally, all facility kitchen staff have training that meet regulation standards. LPA noted that interview with F1 on 02/27/2023 had a concern with R1 having a box of chocolate in their room. LPA noted LIC602A that indicated that R1 had full mental capacity, able to make own decisions for all health care needs and the box chocolate was a personal choice by R1 and not a reflection of the level of staff training. There is not enough evidence at this time to support the allegation of, “Staff are not properly trained.” and is unsubstantiated at this time. Exit interview, report read and provided.

In interviews of R1 by EMT on 10/22/2022 and by LPA on 10/27/2022, R1 indicated no recollection of assault event. Facility had more then enough staff on shift during this time. Facility exercised due diligence, notifications and immediate action pertaining to the circumstances of this incident. There is no evidence to support that the facility was understaffed or negligent in, “Resident physically assaulting another resident in care,” and the allegation is unsubstantiated at this time. As to the allegation of, “Resident is not given showers.” It was discovered through interviews, and documentation that R1 had showers scheduled by staff 7 days per week. From June 2022 through October 2022 there are 21 documented refusals for showers by R1. Interviews with Staff 1 – 5 all confirm that R1 would often refuse showers. Staff 1 – 5 stated they document and report when residents refuse showers. LPA attempted to interview Residents 1 – 6 In memory care as to shower frequency and schedule, however all answers were inconclusive. At this time there is not enough evidence to support the allegation of, “Resident is not given showers.” And is unsubstantiated at this time. As to the allegation of, “Facility did not provide resident with soap.” It was discovered through documentation, interviews and observation that it was observed by LPA that there was pearl-white soap in the soap dispenser on the bathroom sink in R1’s room that was free and clear of grime and/or other substance on 10/27/2022 and 11/17/2022 LPA did not observe any grim or forging substances on the soap dispenser on the wall of the bathroom. Staff duty logs indicate that staff address restocking bathrooms on a weekly basis and as needed. Interviews with S1, S2, S3, S4, S5 and S6 all indicated that soap and other bathroom amenities are stocked regularly and as needed. Based on interviews, documentation, and observations, there is not enough evidence at this time to support the allegation of, “Facility did not provide resident with soap.” and is unsubstantiated at this time. As to the allegation of, “Facility not properly caring for resident’s wounds.” It was discovered that R1 was in need of Podiatrist evaluation as early as November 2022. The facility has a Podiatrist that makes routine bi-monthly rounds, R1 was seen by this Podiatrist on 10/29/2022, 12/13/2022 and refused treatment, again on 12/27/2022 where toenails of R1 were clipped. Additionally, facility contacted R1’s primary physician in January 2023 to evaluate and address R1’s feet and skin care needs. Primary Physician and Nurse Practitioner addressed and treated both foot and skin conditions on January 11, 2023, according to documentation. Based on documentation there is not enough evidence to support the allegation of, “Facility not properly caring for resident’s wounds.” and is unsubstantiated at this time. CONTINUED on LIC9099-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 As to the allegation of, “Resident’s responsible party did not receive a copy of the facility contract.” It was discovered that R1’s initial admission agreement (contract) was signed on September 30, 2017. When R1 added two children as Power of Attorney (POA) in October of 2021, both POA’s were provided copies of the original contract from September 30, 2017. In November of 2021, R1 moved to a higher level of care and into the facilities memory care unit. This was a change of level of care and not a change in the contract. At the time this complaint was issued, POA was assuming that a new contract was necessary for the change in higher level of care and moving to the memory care unit. During the LPAs investigation, the POA had received a copy of the original contract in 2017, in addition to receiving a copy of the original contract in October of 2021. Based on interviews with POA and Administrator, the original contract was provided to the responsible party when requested and the allegation of, “Resident’s responsible party did not receive a copy of the facility contract.” Is unsubstantiated at this time. Exit interview, report read, report singed, and report provided.