Complaint·January 28, 2026

(Continued from Page 1) A review of R1’s Medication Administration Record (MAR) dated July 2025 revealed R1 was given M1 from 07/11/2025 through 07/27/2025. R1 was discharged from the facility on 07/28/2025. The licensee revealed they did not know where R1 transferred to. R1 did not have a cell phone number. Attempts to contact R1’s responsible party were not successful. Regarding the allegation Staff were not providing adequate care and supervision, it was alleged staff was overheard being told by the licensee “don’t help him if you don’t have to”. Based on staff interviews, 3 of 3 staff denied this statement was made by the licensee to them. A review of facility records for R1 was completed. This review included R1’s Bowel Movement Monthly Monitoring Record and Bathing Log. The records were for the month of July 2025. The records indicated services and tracking were being provided by staff. R1 was discharged from the facility on 07/28/2025. The licensee revealed they did not know where R1 transferred to. R1 did not have a cell phone number. Attempts to contact R1’s responsible party were not successful. Regarding the allegation staff did not seek timely medical attention for a resident, it was alleged on 07/04/2025, R1 experienced an event in which staff asked the licensee if they could call a nurse, but the licensee said no. Based on staff interviews, 3 of 3 staff denied this allegation. The interview with the licensee revealed R1 indicated they were in pain and staff called 911. When medical professionals arrived, R1 refused to go with them to the hospital. The LPA requested documents regarding this event and was told that if the facility had documents they would have provided them to the LPA. The LPA did not receive documents regarding this event. R1 was discharged from the facility on 07/28/2025. The licensee revealed they did not know where R1 transferred to. R1 did not have a cell phone number. Attempts to contact R1’s responsible party were not successful. Regarding the allegation staff did not meet a resident’s hygiene need, it was alleged R1 had not received a shower in a week. Based on staff interviews, 3 of 3 staff denied this allegation. A review of R1’s Bathing Log for the month of July 2025 revealed that R1 refused a bath on 07/18/2025 because the staff that R1 preferred was not working. It further documented R1 received a bath 3 days a week for the month of July 2025. R1 was discharged from the facility on 07/28/2025. The licensee revealed they did not know where R1 transferred to. R1 did not have a cell phone number. Attempts to contact R1’s responsible party were not successful. (Continued on Page 3) (Continued from Page 2) Regarding the allegation staff do not communicate effectively, it was alleged staff do not speak English. Based on staff interviews, 3 of 3 staff denied this allegation. The LPA interviewed all 4 residents. The resident interviews revealed 2 of 4 indicated they were able to communicate effectively with staff. As for the remaining 2 residents, 1 did not want to participate in the interview and the other was unable to answer questions posed in the interview. Regarding the allegation staff were retaliating against a resident, it was alleged R1 felt they were being retaliated against by the licensee. The interview with the licensee was completed and she denied retaliating against R1. Based on staff interviews, 3 of 3 staff denied this allegation. It could not be determined how the licensee specifically retaliated against R1. R1 was discharged from the facility on 07/28/2025. The licensee revealed they did not know where R1 transferred to. R1 did not have a cell phone number. Attempts to contact R1’s responsible party were not successful. Regarding the allegation staff were overcharging a resident, it was alleged the licensee was charging R1 more than the standard Supplement Security Income (SSI) rate. The licensee denied overcharging R1. A review of R1’s Admission Agreement dated 01/03/2025, revealed a section that allows for it to be indicated whether the resident’s source of funding included SSI/SSP funding or it does not include SSI/SSP funding. Neither option was marked. The licensee reported R1’s source of funding was insurance. The licensee reported the facility had never received any payment for R1 since R1’s admission on 01/03/2025. R1 was discharged from the facility on 07/28/2025. The licensee revealed they did not know where R1 transferred to. R1 did not have a cell phone number. Attempts to contact R1’s responsible party were not successful. Based on the investigation, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Zainab Choudry and a copy of this report along with LIC811- Confidential Names list was provided.