Complaint Investigation Report

The Complainant alleged that on 01/06/2026, Licensee did not allow C1 to receive their outside visitor, P1. However, interviews showed that P1 did not physically come to facility premises seeking to enter or meet with C1, either on that day or any other day. Interviews of Licensee and P1, corroborated by electronic correspondence, aligned to show: Around this time, Licensee and P1 communicated via phone. Licensee did not prohibit P1 from visiting C1 at the facility. Rather, P1 changed their own mind and decided not to visit C1. P1 said they did not believe C1’s visitation rights were violated. P1 affirmed that Licensee was cordial/professional with them. LPA interviewed 3 of 3 other clients in care, each of whom denied Licensee’s staff ever interfering with their own ability to receive visitors.

The Complainant alleged that during early January 2026, C1 had self-inflicted cigarette burns on their left forearm and hand, and that Licensee did not arrange timely medical care for these. They alleged that C1 had a productive cough, and that Licensee did not take C1 to urgent care, as C1 requested. They also alleged that C1 requested to have a therapist for their mental health needs, and that Licensee did not follow up on this.

Interviews of C1 and staff aligned to show: Licensee’s staff quickly discovered/identified C1’s cigarette burns and timely contacted C1’s nurse practitioner (NP), who worked under C1’s primary care physician (PCP). Licensee’s staff sent the NP photographs of the affected areas on C1’s arm and hand, which the NP reviewed. The PCP/NP advised that based on these photographs, C1 did not require urgent care or hospital attention that day. They further instructed facility staff to send them updated photographs three (3) days later, which Licensee’s staff indeed completed. Upon receipt of the second round of photos, the PCP prescribed a 10-day antibiotic for C1, which facility staff gave to C1 as prescribed. The PCP and NP then both visited C1 at the facility at the conclusion of the antibiotic treatment, verifying that C1’s arm and hand were continuing to heal well. C1 was then prescribed a topical ointment to continue applying. During his own 01/15/2026 visit, LPA observed that C1’s burns were closed and scabbed over, and that this ointment was on top of said scabs, as expected.