complaint·September 30, 2025

[CONTINUED FROM LIC 9099] The Complainant claimed that around 02/17/2021, R1 sustained a large skin tear on their right leg and two smaller skin tears on their left leg, and that around 03/04/2021, R1 sustained a small skin tear on their face/cheek and abrasions on their lips. The Complainant said that R1 appeared distrustful of facility staff, who the Complainant suspected caused R1’s injuries. Hospice care records showed: Around the time R1 moved into Sunview Gardens 2 in December 2021, R1 was diagnosed with “cerebral infarction [aka ‘stroke’]” and “dementia with behavioral disturbance,” was “forgetful, disoriented, and agitated,” experienced pain during movement/repositioning, was restless, and had sundowning confusion. R1’s skin, which had baseline “poor turgor,” was susceptible to “bruising” and damage from bedsheet “friction and shear.” R1’s hospital bed also had bedrails on it. R1’s intermittent agitation, restlessness, and combativeness persisted throughout the next few months. Medication was not always effective at calming R1. Sometimes R1 would spit out their medication. During late January 2021, R1 received Abreva for treatment of a cold sore on their lip. On 02/17/2021, a hospice Registered Nurse (RN) conducted a follow-up visit to address a skin tear on R1’s right leg and bruising to both legs, which occurred “during a period of increased anxiety and agitation.” Facility staff cleaned and dressed R1’s skin tear prior to the RN’s arrival. During said visit, the RN was unable to assess R1 further due to “[patient] agitation.” The RN wrote that R1 had a mild fever with “foul smelling urine,” which were indicative of a Urinary Tract Infection (UTI). That same day, R1’s hospice physician ordered a 7-day course of antibiotics for R1 and increased the allowed dosage of their as-needed antipsychotic medication, used to treat “uncontrolled anxiety.” Subsequent hospice notes tracked the healing of R1’s legs and mentioned R1 “has [had] multiple infections of the eye, lip, and UTI,” and that R1 remained “prone to severe bruising and closed skin tears to lower legs due to self injury during agitation.” During a 03/02/2021 visit, a hospice Licensed Vocational Nurse (LVN) tried unsuccessfully to perform a dressing change on R1’s right calf. R1 “began to kick and sink nails into any skin [they] could reach.” A hospice RN visited R1 on 03/03/2021, upon arrival finding R1 in bed with both of their legs “over side of bed.” They wrote R1 was alert but “confused” and “paranoid,” speaking in a “non-sensical” manner and intermittently crying. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] R1’s hospice doctor made multiple adjustments to R1’s medication regimen and subsequent visits from hospice nurses were increased from once per week to five (5) times per week. During 03/04/2021 visit, a hospice RN wrote that R1 had a “new open mark” on their right facial cheek; it was an “approximately 2 cm X 1 cm oblong circle.” R1 also had redness/abrasion on their upper and lower lips. The nurse documented that during this visit, R1 was “lying in bed smiling” upon their arrival, was “talkative, alert, and oriented to self,” speaking about their family, denying pain, and agreeable to consuming yogurt and medications. The RN wrote that facility staff could not specify how R1 sustained their cheek injury, but also that R1 was awake and yelling during the preceding night, per staff. LPA was unable to interview R1 for this case, due to R1 having moved out by the date the complaint was received, and due to R1 having passed away shortly thereafter. Yet nothing in the hospice records ever showed R1 claiming someone at the facility had physically abused them or caused the injuries in question. LPA interviewed multiple outside sources and 2 of 2 managers and 10 of 11 caregivers who worked at the facility during the complaint timeframe. (One caregiver had since left employment and could not be reached for interview). The interviews did not corroborate facility staff physically abusing R1 or being too rough in their handling of R1. On the contrary, multiple staff interviews showed that R1 had on occasion scratched themselves and/or hit their own arms/legs into their hospital bed’s railing (requiring staff to add padding). Based on records and interviews, a preponderance of evidence does not exist to show that Licensee’s staff injured resident. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Lead Caregiver Michelle Rodriguez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. An electronic set of these same documents was E-mailed to Licensee/Administrator Felicity Arcangeli.