Complaint·February 24, 2026

On September 1, 2025, staff 1 (S1) observed additional bruises on R1 neck as R1 was leaving the facility with family. Review of staff notes indicated bruising may have occurred around the same time R1 had physical altercations with R2 on 08/27/2025 during the nocturnal shift. On September 1, 2025 R1 was taken to the hospital where bruising was confirmed; no fractures were noted. Document review revealed that between July 2, 2025, and August 2025, R1 prescription dosage increased from 20mg to 50mg indicating it was for behavioral management which occurred during the same time that R1 had multiple altercations with resident. Although bruising was observed, the Department could not determine the exact source of the bruising. Therefore, based on interviews conducted and records review, the allegation, resident sustained bruising due to an unknown cause is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed, and a copy was provided to Rachelle Llamas, Executive Director.