LPA conducted a tour of the facility and inspected all shower chairs but did not observe anything protruding from the sitting area. However, LPA observed one shower chair with torn back cushion with exposed sponge material that appeared to be in such condition for extended periods. Based on observation, the evidence found during the investigation met the preponderance of evidence standard. Therefore, this allegation is substantiated.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was provided, along with a copy of LIC9099D and Appeal Rights.

LPA conducted interviews with six (6) residents, all of whom denied being physically abused by staff. All residents interviewed stated that staff have been very careful when providing care. LPA conducted interviews with seven (7) staff members, all of whom denied pulling or dragging residents’ feet. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 had two (2) visitors at the time. R1 and both visitors did not suspect the bruises were from staff’s neglect or abuse. R1 stated that staff were very careful when providing assistance. R1 did not have any concerns regarding staff assistance with mobility. R1 and the visitors were not certain what or who caused the bruises on R1’s legs.

There is insufficient evidence available to show that resident sustained multiple bruises due to staff neglect or physical abuse. The available documents are not sufficient to determine the cause of the bruises. Interviews conducted did not reveal any causes of the bruises. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time.

It was alleged that staff are not meeting resident’s hygiene needs. Information received indicated that there is inadequate staff assistance with Resident #1’s (R1) hygiene needs. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 had two (2) visitors at the time. R1 was brushing her teeth with some assistance from one of the visitors. LPA conducted an interview with R1, who stated that they did not remember when the facility staff members assisted with daily oral hygiene. LPA conducted interviews with six (6) residents, all of whom did not have any concerns with staff assistance with daily hygiene. LPA conducted R1’s records review. LPA reviewed the facility care logs from January 2026 through July 2026. LPA observed that staff had provided assistance with oral hygiene twice daily. LPA observed that staff had not missed any.

Based on interviews conducted and records review, there is insufficient evidence to prove that staff are not meeting resident’s hygiene needs. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time.

Continued on LIC9099-C....

LPA conducted interviews with six (6) residents, all of whom denied ever being confined to wheelchairs or beds. LPA conducted interviews with seven (7) staff members, all of whom denied ever witnessing residents confined to wheelchairs or beds. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 stated that R1 never said anything about being confined to wheelchair or bed. R1 was happy about staff members’ encouragement to get out of bed and participate in activities.

Based on interviews conducted, there is insufficient evidence to prove that staff confine resident to wheelchair/bed. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time.

It was alleged that staff handled resident inappropriately. Information received indicated that staff grabbed Resident #1 (R1) by their feet and dragged out of bed. Per physician’s report dated November 3, 2025, and R1’s assessment, R1 uses wheelchair and required staff assistance for all activities of daily living (ADL), including transfer to and from wheelchair due to R1’s cognitive and physical condition.

LPA conducted interviews with six (6) residents, all of whom denied ever being dragged out of beds. LPA conducted interviews with seven (7) staff members, all of whom denied ever witnessing staff dragging residents out of beds. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 stated that R1 never said anything about being grabbed by the feet and dragged out of bed by staff members. R1 had never experienced such incidents in the facility. R1 thought staff were polite and careful to residents in care.

Based on interviews conducted, there is insufficient evidence to prove that staff handled resident inappropriately. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time.

Continued on LIC9099-C....

LPA conducted interviews with six (6) residents, all of whom denied experiencing staff speaking inappropriately to residents. LPA conducted interviews with seven (7) staff members, all of whom denied witnessing or speaking inappropriately to residents in care. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 denied telling anyone that the facility staff spoke inappropriately. R1 had never experienced such incidents in the facility. R1 thought staff were polite and careful to residents in care.

Based on interviews conducted, there is insufficient evidence to prove that staff speak to resident inappropriately. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time.

It was alleged that staff withhold resident’s medication. Information received indicated that staff withheld Resident #1’s (R1) medication prescribed for their skin condition. LPA conducted interviews with six (6) residents, all of whom denied experiencing staff withholding their medication. LPA conducted interviews with seven (7) staff members, all of whom stated that staff strictly follow what is in residents’ prescriptions. All staff members interviewed stated that medication administration record (MAR) shows all residents’ records.

LPA conducted R1’s records review. R1’s MAR shows the medication for skin condition were administered in May 2026 and June 2026 but not in July 2026. LPA conducted an interview with Anguiano, who stated that the medication for R1's skin condition was discontinued by R1's physician. LPA conducted review of R1's medication records which revealed that the medication ended on June 24, 2026. R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 stated that staff stopped applying the prescribed medication for their skin condition but was not able to tell any time frame.

Based on interviews conducted and records review, there is insufficient evidence to prove that staff withhold resident’s medication. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time.

Continued on LIC9099-C....

R1 is currently admitted to a skilled nursing facility for rehabilitation. LPA conducted an interview with R1 at the skilled nursing facility. R1 stated that R1 never said anything about inadequate staff assistance with mobility. R1 was happy about staff members’ encouragement to get out of bed and participate in activities. R1 stated that staff had always provided good assistance with mobility while R1 resided at the facility.

Based on interviews conducted, there is insufficient evidence to prove that staff do not assist resident with mobility. The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, this allegation is unsubstantiated at this time.

The evidence found during the investigation did not meet the preponderance of evidence standard. Therefore, 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.