Complaint Investigation Report

Regarding the allegation that “Resident sustained injuries from lack of care and supervision,” LPA interviewed three staff regarding this allegation, and three of three staff denied that R1 sustained injuries as a result of neglect, lack of care, or lack of supervision by facility staff. For this allegation, LPA reviewed R1’s 2026 physician report, including skin observation notes, nurse practitioner notes, home health follow-up notes, physical therapy notes, and documented change-of-condition notes. The reviewed records documented that R1 had left eye ecchymosis on 01/19/2026, bumps on the top of the head on 02/06/2026 and 02/21/2026, yellow discoloration to the sides of the face on 03/17/2026, and a raised area to the upper right side of the back on 03/21/2026. The reviewed records also documented that the nurse practitioner was notified, monitoring and follow-up were documented, and the nurse practitioner advised on 03/17/2026 that the yellow discoloration appeared to be a normal healing bruise. The records did not establish that R1’s injuries or skin concerns were caused by lack of care or supervision by facility staff. Regarding the allegation that “Licensee is not responding to responsible party,” LPA interviewed three staff regarding this allegation, and three of three staff denied that the licensee failed to respond to R1’s responsible party. For this allegation, LPA reviewed the complaint report and R1’s 2026 physician report, including documentation related to responsible party communication. Records dated 03/13/2026 documented that facility staff communicated with R1’s responsible party regarding R1’s son’s visit and provided updates regarding R1’s home health and physical therapy services. LPA also attempted to contact the reporting party on 06/02/2026, 06/04/2026, and 06/12/2026; however, LPA was unable to reach the reporting party and did not leave a voicemail due to the complaint instruction not to leave one. Regarding the allegation that “Facility staff did not report incident to responsible party,” LPA interviewed three staff regarding this allegation, and three of three staff denied that facility staff failed to report an incident or change in condition to R1’s responsible party. For this allegation, LPA reviewed R1’s 2026 physician report, including responsible party communication notes, nurse practitioner notification notes, change-of-condition notes, and medical follow-up documentation. Records reviewed documented that the nurse practitioner was notified regarding multiple changes in condition, including entries dated 01/07/2026, 02/06/2026, 02/21/2026, 03/10/2026, 03/17/2026, 03/21/2026, 05/15/2026, 05/21/2026, 05/26/2026, and 06/11/2026. {***CONTINUE9099C***}