complaint·February 18, 2026

LPA’s review of R1’s record revealed that R1 arrived on 07-26-2021 and moved out on 07-29-2021. R1 returned to the skilled nursing facility where R1 was transferred from after request was made by the facility staff. R1 had resided for three (3) days at the facility. LPA’s record review revealed that R1’s resident file was no longer available for review. LPA conducted an interview with Staff #2 (S2) who stated that R1’s resident file was no longer available due to expiration of resident record retention periods. Based on record review, the Department’s investigation did not find enough information to corroborate the allegation that facility retained resident requiring a higher level of care. This allegation is unsubstantiated. It was alleged that resident did not receive medication as prescribed. Information received indicated that R1’s medication did not arrive when R1 moved in from a skilled nursing facility. LPA’s review of R1’s record did not reveal any history of R1’s medication. LPA’s interview with Staff #2 (S2) revealed that R1’s resident file was no longer available due to expiration of resident record retention period. R1’s progress notes were the only record available at the facility. R1 moved in on 07-26-2021 and returned to the skilled nursing facility on 07-29-2021 per R1’s progress notes. The Department conducted an interview with S1 who stated that R1 arrived with a list of medications but without doctor’s order. Doctor’s order for R1 came in from the skilled nursing facility on the day after R1’s arrival. LPA conducted interviews with eight (8) residents, all of whom stated that staff have provided medication dispense services as prescribed. Based on record review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that resident did not receive medication as prescribed. This allegation is unsubstantiated. It was alleged that staff did not treat resident with dignity and respect. Information received indicated that facility staff did not assist R1 with feeding. R1’s relevant party observed a food tray next to R1’s bed while R1 was still in bed. LPA’s review of R1’s record revealed that R1’s care plan and assessment were no longer available for review. LPA’s interview with Staff #2 (S2) revealed that R1’s resident file was no longer available due to expiration of resident record retention period. LPA could not determine if R1 required assistance with feeding. LPA conducted interviews with eight (8) residents, all of whom stated staff treat residents with respect. Based on record review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff did not treat resident with dignity and respect. This allegation is unsubstantiated. Continued on LIC9099-C.... It was alleged that staff did not follow COVID-19 protocol. Information received indicated that R1 did not receive COVID-19 test prior to entering the facility and was permitted to eat in the dining room with other residents. LPA conducted review of R1’s records, but R1’s resident file was no longer available for review. LPA conducted an interview with S2 who stated that R1’s records were not available due to expiration of resident records retention periods. R1’s progress notes were the only record for R1. Per the record, R1 arrived on 07-26-2021 from a skilled nursing facility and returned to the skilled nursing facility on 07-29-2021. The Department’s interview with S1 revealed that R1 already had COVID test or vaccination card as R1 came from a skilled nursing facility. The Department’s interviews with S1 and a resident ambassador revealed that staff had followed COVID protocol. LPA conducted interviews with eight (8) residents, all of whom stated that staff have followed COVID protocol. Based on record review and interviews conducted, the Department’s investigation did not find enough information to corroborate the allegation that staff did not follow COVID-19 protocol. This allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.