complaint·July 29, 2025

Interviews with S2, S3, and S5 reported providing verbal communication to staff on changes of condition and new procedures. It was reported after R1 conditioned worsen staff started a daily log or charting changes in R1 condition. This new procedure required caregiver to chart resident’s daily activities or behaviors such as showers, food intake, bowel movements, behaviors, complete a shower check list, and skin condition. It was found that R1 was diagnosed with Stage 1 pressure injury and required assistance with all daily living activities. There was no charting or log to identify changes in R1 condition. Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.