complaint·March 3, 2026

Report Continued from LIC 9099... During the initial visit on 08/20/2025, LPA Chochian reviewed and obtained copies of pertinent documents between 01:30 p.m. and 02:00 p.m. and toured the physical plan area at approximately 02:15 p.m. On 02/23/2026, LPA Arroyo conducted an interview with the Administrator at 12:35 p.m. and obtained copies of pertinent documents relevant to the investigation. Investigator Garcia conducted interviews on 09/18/2025, at approximately 06:52 p.m., with the Administrator; at approximately 12:30 p.m., with a staff member; and at approximately 01:00 p.m., 01:30 p.m., and 02:00 p.m. with three residents. Additional interviews were conducted by Investigator Garcia on 10/14/2025, at approximately 04:22 p.m., with a family member; and on 12/03/2025, at approximately 04:00 p.m., with the Home Health Nurse Director. Additionally, hospital records were requested on 08/22/2025 and received on 08/28/2025 and home health records were requested on 01/22/2026 and received the same day. A review of R1’s Physician’s Report dated 05/26/2025 listed R1’s primary diagnosis as dementia, with secondary diagnoses of hypertension, hyperlipidemia, and deep vein thrombosis/pulmonary embolism. The report described R1’s mental condition as confused and disoriented due to dementia; however, R1 was able to follow simple instructions and communicate basic needs. The report further indicated that R1 was non-ambulatory and required standby assistance, had no capacity for self-care, and required assistance with all activities of daily living (ADLs). The investigation revealed that R1 was admitted to the facility on 05/26/2025 with prescriptions for two different blood thinning medications, Eliquis and Pradaxa, which were identified as the primary cause of R1’s bruising. Interviews with staff indicated that R1 was admitted to the facility because R1’s family was unable to continue providing care due to R1’s self-injurious behaviors and significant cognitive decline. Staff reported that R1 exhibited aggressive behaviors toward both self and others within the facility. These behaviors included kicking, biting, spitting, throwing themselves onto the floor, screaming, and defecating and smearing feces throughout the room. The Administrator stated that there was ongoing communication with R1’s primary care physician (PCP) regarding R1’s needs, including requests for medication adjustments and additional support. However, there were reported delays in receiving responses from the PCP. Report Continued on LIC 9099C... Report Continued from LIC 9099C... According to discharge documentation from R1’s hospital visits on 08/06/2025 and 08/12/2025, the issues addressed included a urinary tract infection (UTI), aftercare following hospitalization, major neurocognitive disorder, moderate, with agitation, a history of recurrent deep vein thrombosis, and a gluteal hematoma related to the use of blood thinners. During the 08/12/2025 visit, R1’s PCP discontinued Pradaxa and instructed that R1 continue taking Eliquis as prescribed for recurrent venous thrombosis. R1 was also admitted to home health services with Pegasus Home Health. However, following a hospital visit on 08/19/2025, R1 was placed on hospice care with Luna Hospice, Inc., with a primary diagnosis of senile degeneration of the brain, not elsewhere classified. Interviews conducted with residents revealed that there was constant supervision provided both during the day and at night, and that staff were described as extremely caring. Additionally, three out of three residents interviewed denied any type of neglect or lack of care by facility staff and reported feeling safe while residing at the facility. Based on the information obtained during the course of the investigation, the Department has insufficient evidence to support the allegation, therefore allegation “due to staff neglect and lack of supervision, resident sustained multiple bruises” is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy issued.