Complaint·January 23, 2026

[Continued from LIC 9099] R1 is a bed-ridden resident at the facility with a diagnosis of Dementia. Three (3) separate interviews with outside sources central to R1's medical care corroborated that R1 has thin skin, with one (1) additionally noting that R1 has a history of bruising and hitting themselves against their bed railings, along with an aversion to touch. Two (2) noted reports of increased agitation and aggression by R1 towards care staff, but revealed no concerns about R1's care at the facility. R1 having thin or fragile skin and easily bruising was corroborated by two (2) facility staff members, and one additional staff member interviewed stated that R1 tends to occasionally get agitated and begin wrapping sheets around their hands, or hitting things around them. Four (4) facility staff members corroborated that R1 has aggressive behaviors, with two (2) specifying they tend to increase around toileting. Per staff interviews, R1 constantly requests toileting assistance but then will not want to be assisted by staff and becomes combative. One (1) staff member interviewed stated that on one such occasion R1 began wrapping their hands in blankets then hitting their hands and arms against their side table and bed railings, resulting in bruising. Resident interviews revealed no concerns regarding their care at the facility. An additional outside source interviewed also corroborated an increase in R1's agitated and combative behaviors, and attributed them to R1's Dementia. File review of R1's records note R1's behaviors of disorientation but none regarding aggressive behaviors. Additional file review of hospice records revealed an order for a medication to help with R1's "agitation/restlessness." Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred – therefore the allegation have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Administrator Puentes to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.