Facility Evaluation Report

Licensing Program Analysts (LPA) Albert Johnson and Jason Lund arrived unannounced to conduct a case management visit. LPAs met with Joshua Riviera and explained the purpose of the visit.

The RO referred this case to the Investigations Branch (IB), to investigate the allegation that staff failed to seek timely medical care for R1 which resulted in R1's death. Finding: Unsubstantiated

R1 was experiencing vomiting multiple times on 6/1/2025. Medication Services Assistant (MSA) reported R1 was vomiting at approximately 1600 hours. MSA monitored R1 and when her symptoms did not improve, R1 was sent to the hospital at approximately 1900 hours.

R1 had a history of constipation and had a small bowel obstruction procedure in 2018. While in the hospital, a scan of the abdomen and pelvis revealed a large amount of stool in the colon, suggesting constipation and a probable mid small bowel obstruction. R1 reported her pain resolved after receiving an enema and passing a large solid bowel movement on 6/2/2025.