complaint·April 10, 2026

The reason for the amendment is to remove confidential information. The finding will remain unsubstantiated. See hard copy for signature. In regard of allegations: Resident sustained unexplained injuries and Staff did not report incidents to authorized representatives. It was alleged that R1 was observed with bruises, lacerations, and skin tears and staff didn’t provide timely and accurate report to residents representative. During the investigation, the LPA interviewed the Administrator, staff, residents, and family members. The Administrator and staff denied the allegations. They stated that staff at the facility have not caused any injury to R1 or any other resident and that staff always provide timely and accurate reports to residents’ representatives. R1 was admitted to the facility on 06/29/25 under Hospice care with a history of skin condition and with a G-tube. Administrator stated that R1 had existing bruises due to prescribed blood-thinning medications that were administered per Hospice orders. The Administrator also stated that R1 had sensitive skin and frequently experienced itching and scratching. According to the Administrator, the itching was a side effect of prescribed medications. LPA spoke with Hospice nurse and reviewed R1’s file and Hospice documentation, which explained why R1 is prone to bruising easily. From discussions with the hospice nurse and a review of hospice and facility documentation, LPA learned that certain medications prescribed by the physician may cause side effects such as itchy skin, rashes, and increased or unexplained bruising, which can make it easier for blood to pool under the skin. They stated that they were at the facility often and were in communication with the staff and R1’s family members. Hospice nurse stated that they didn’t observe any neglection from facility administrator and staff. However at the time of visits specifically on the dates of 8/16/25 8/18/25, 8/20/22 and 8/27/25 they observed evidence of cellulitis, skin discolorations, left jaw swelling likely related to bed rail contact and a left calf wound which was later ruled out. At the time of conversation nurse expressed an opinion that skin discoloration and jaw swelling were because of side effects of medications that were prescribed by the doctor. They may cause unusual bruising or bleeding on the skin, may cause hives or itching as a reaction. Also they mentioned that calf wound was the result from the compression wraps. Nurse stated that observations were communicated with facility staff and R1’s family members and proper care was continuously provided to R1. The hospice nurse further stated that R1’s family expressed no concerns regarding the care provided by hospice and facility, which supported that the issue stemmed from a miscommunication between the facility and hospice rather than lack of proper care. LPA also spoke with R1’s responsible party, who maintained regular contact with R1, Hospice agency and the facility staff. The responsible party explained possible reasons why R1 sustained bruising on their body and skin. Continue 9099C The Administrator stated that the facility maintained regular communication with R1’s family members, responsible party, and Hospice regarding R1’s condition. The Hospice nurse was informed and aware of R1’s ongoing scratching behavior. Family members and the responsible party were informed during regular visits. The Administrator, S1 and S2 stated that R1 was repositioned regularly and monitored for skin integrity. Staff also applied Hospice provided cream for R1’s sensitive skin. The Administrator and staff further stated that Hospice was immediately informed of any changes in R1’s condition. Interviewed S1 and S2 stated that they have never observed any staff member handling residents in a manner that could cause harm or bruising. They stated that in the event of any skin condition changes, bruises, lacerations, or skin tears, staff immediately informed the Administrator, who then contacted Hospice for assistance. The LPA interviewed R1’s responsible party (FM1) and FM2. FM1 stated that they visited R1 regularly and were satisfied with the care R1 received at the facility. FM1 reported having no concerns regarding R1’s care and expressed appreciation for the attention and continuous care provided by the facility during R1’s stay. FM1 also stated that R1 tends to scratch themselves and that R1’s thin and sensitive skin may have contributed to bruising, lacerations, or skin tears. FM1 stated that R1 was taking medications that made their skin bruise easily and mentioned that this condition may be genetic, as they experience similar issues. Interviewed FM2 stated that the facility Administrator and staff provided attentive care and treated R1 with dignity. FM2 indicated that R1 always appeared happy during visits and that the staff and residents became like family. FM1 and FM2 stated that if they ever had concerns regarding R1 care, they would immediately raise them with the Administrator and report them to the appropriate agencies if necessary. The LPA also interviewed R2 and R3. They stated that all residents, including R1, have always been treated with kindness, respect, and professionalism, and they are satisfied with the quality of care provided at the facility. They also stated that R1’s family members visited frequently and maintained a good relationship with staff and residents. R2 and R3 further indicated that the Administrator and staff would immediately contact family members or responsible parties if any incident occurred. Based on statements and interviews conducted with staff, residents, and family members, as well as a review of resident and facility records, there was insufficient evidence to support the reported allegations. Although the allegations may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. Therefore, the allegations are determined to be Unsubstantiated. Exit interview was conducted and the copy of this report was provided to Francisco Moreno.