Complaint·July 11, 2025

[Continued from LIC9099] Review of R1's physician's report revealed that R1  uses a walker to ambulate to help with gait and balance; however, the needs and the service plan revealed that R1 is noncompliant with medical aides. Review of records revealed that R1 was noted to have episodes of increased confusion due to a diagnosis of vascular dementia. Per record review and staff interviews on November 17, 2025, R1 was receiving assistance from S1 while exiting their room.  R1 was agitated and expressed a desire to leave their room to get breakfast at approximately 11:30 PM. S1 attempted to assist R1 back into bed, but R1 swung their arms and struck the doorframe. In the process, S1 grasped R1 by the arms, which may have contributed to the bruises and skin tears observed on R1's hands and arms. A medical technician assessed R1 and provided first aid to R1 at the time of the incident.   Interview further reveal that S1 denied handling R1 in a rough manner and stated S1 was trying to protect themselves while also ensuring R1’s safety. Further records review and Staff interview reveal that on 11/9/2024 , R1 had a previous fall sustaining two skin tears on their right knee and excoriation on their right back shoulder. Interviews with staff and review of evidence reveal it is unknown if R1 caused the skin tears on R1's arms. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove physical abuse by staff. The allegations were deemed unsubstantiated. An exit interview was conducted with Administrator Garza, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail. A reply E-mail or read receipt confirmation was requested from Garza upon receipt of documents.