Complaint·September 17, 2025

(Continued from LIC9099 p.1) Staff informed that the hospice agency assessed R1 and a care conference was held regarding R1's change in condition, prescription update, and self-induced injuries that were occurring during the episodes of agitation. During an unannounced facility visit LPA interviewed R1. LPA observed R1 to have bruises along their left arm and one bruise on their left leg during the facility visit. R1's explanations for these bruises were implausible due to R1 stating the left leg bruise was due to a pole on the wall that did not exist per LPA's observation, and that the arm bruises were due to an unknown person coming into R1's room years ago and hitting them. R1 resided in the facility's Memory Care unit and was not able to be qualified as a valid historian. LPA attempted to contact three (3) outside sources for interview. LPA spoke with a hospice worker familiar with R1 who verified staff statements regarding R1 having frequent outbursts and attempting to climb out of their bed, resulting in falls. Additional requests for interviews from R1's hospice agency and an outside advocacy agency familiar with R1 were not returned. Review of facility records during the timeframe of complaint showed staff documentation and communication to R1's hospice agency regarding bruising, frequent falls out of bed, agitation, and hallucinations by R1 that someone came into their room in the night and hit them. These records corroborated staff statements, outside source interview statements, and LPA direct observations during interview with R1. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Kitchen Supervisor Andres Barragan, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.