complaint·July 15, 2025

It was alleged that facility is not following Physical Therapy orders resulting in worsening of pressure ulcer. LPA Rodriguez conducted a total of 5 interviews that consisted of residents and staff, of which all 5 interviews did not corroborate with the allegation. Per interviews and record review, resident 1 (R1) was admitted to facility, after getting discharged from the hospital due to a hip fracture that was sustained. During the investigation, an interview was conducted with R1's responsible party, and it was revealed that although R1 had redness and soreness on R1's tailbone, there was never an instance where R1 had a pressure ulcer. In addition, there were no documents presented from the facility, the hospital, and from home health that R1 ever had a pressure ulcer. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with AD Mejia and AD Fuentes. A copy of this report was provided and explained.