complaint·September 25, 2025

R1’s Physician Report established that R1 does not require continuous monitoring or continuous bed care According to the second allegation, neglect to R1 resulted in multiple stage 1 and stage 2 pressure injuries to genital area and ankle. Facility records revealed R1 was admitted with a quarter size scab to the ankle. Records also revealed that R1 has a history of skin breakdown prior to admission. Staff interviews did not reveal any information to corroborate that R1 was neglected resulting in pressure injuries. The third allegation states facility retained R1 who required a higher level of care. Records collected revealed facility conducted a pre-admission appraisal and found R1 to be at facility’s level of care available. Physician report dated January 16, 2023, did not show any restricted or prohibited diagnosis. Interview with staff revealed there were no issues with the level of care required by R1. According to the fourth allegation, the facility did not address R1’s ten-pound weight loss while in care. Records were unable to confirm R1 lost the weight during the eight day stay at the facility. Interview with staff could not corroborate that R1 was not monitored or R1’s changes were not identified during R1’s stay. According to the fifth allegation, R1 was not given enough fluids resulting in dehydration. Interview with multiple staff revealed residents are given water or juice throughout the day in addition to the beverage with their meals. Interview with other residents reveal residents are provided with numerous drinks throughout the day. There were no records documenting R1 as dehydrated. The sixth allegation states facility staff were not responding timely to call button. Interview with staff could not establish that facility was not responding timely to call button. Records collected could not establish facility staff were not responding timely to residents in need. Interview with residents revealed that they are assisted within a few minutes of requesting assistance. The seventh allegation states R1 was not provided with any clean clothing. Interview with laundry staff revealed that laundry is done regularly and there is one full time employee conducting laundry service. Interview with residents revealed that they do have full laundry service. LPA Strong observed laundry service and confirmed such information. According to the eighth allegation, R1 was only fully showered one time during R1’s stay. Interview with staff revealed that residents also receive sponge baths as well as showers. Interview with residents established that facility staff provide residents with bi-weekly showers or sponge baths depending on resident. Interview with staff could not establish that facility staff only provided R1 with one shower during stay. Lastly is was alleged that R1 was not assisted with toileting needs. Interview with staff could not establish that R1 was not assisted with toileting. Interview with residents established that they are changed frequently or assisted to the restroom when requested. There were no records available to corroborate allegation. Based on interviews, records available and observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Clinical Director Yolanda Torres and Director Jonathan Wheeler to whom a copy of this report, and the Licensee/Appeal Rights were provided.