LPA Khurshudyan conducted interviews with eleven (11) residents in the Memory Care Unit who were able to communicate and respond to questions. All residents interviewed denied ever witnessing or hearing of any resident being physically abused or receiving bruises from physical abuse. Residents stated they liked the facility, felt comfortable living there, and felt adequately supervised by staff.

LPA interviewed four (4) Staff members, who denied ever witnessing or being aware of any physical abuse that could have resulted in residents obtaining bruises. Staff reported that residents in the Memory Care Unit are monitored throughout the day, and any unusual skin discoloration, injury, or change in condition is reported to the Memory Care Director and/or management.

To investigate the allegation, the Department also interviewed Memory Care Director MCD. MCD stated that R1 had ongoing behavioral issues and was frequently observed hitting hands on doors and walls and hitting self.

The Memory Care Director (MCD) reported that R1 was being closely monitored due to behavioral changes and increased agitation. The MCD also confirmed that R1 was evaluated by a physician and diagnosed with a UTI on 5/24/2025. The Department attempted to interview R1; however, due to R1’s inability to respond and increased agitation, the interview was terminated.

Although R1 had bruising and discoloration on the hands and left wrist, the information obtained during the investigation did not establish that the bruising resulted from physical abuse, neglect, or lack of supervision by facility staff. Based on interviews, record reviews, and all information obtained, there is insufficient evidence to determine that the bruising was unexplained due to neglect or abuse by the facility.

Therefore, the allegation is Unsubstantiated.

Allegation: Staff did not notice residents change in condition.

The investigation conducted by LPA Khurshudyan, revealed that facility staff documented changes in R1’s behavior and condition beginning on or around 5/21/2025. Facility progress notes documented that R1 had increased behavior, agitation, difficulty with redirection, and possible symptoms related to UTI. Facility records documented that staff attempted to obtain a urine sample and continued to monitor R1.

Continue on LIC9099-C

Based on interviews and records reviewed, LPA Khurshudyan determined that facility staff observed and documented R1’s change in condition, including behavioral changes, agitation, possible UTI symptoms, and skin discoloration. Staff also took steps to monitor R1, report concerns, coordinate with the responsible parties, and seek medical evaluation. Therefore, the allegation staff did not notice residents change in condition is Unsubstantiated.

Allegation: Staff did not notify authorized representative of bruises.

It was alleged that the authorized representative was not notified regarding R1 bruising/ discoloration. Records reviewed by LPA Khurshudyan confirmed that communication was documented between facility staff and R1’s family/responsible party regarding R1’s behavioral condition and agitation. LPA Khurshudyan also conducted interview with the Memory Care Direcotor MCD, who stated that staff were actively monitoring R1 and documented everything. On 5/23/25, a staff member reported observing discoloration on R1’s hands. The Memory Care Director (MCD) also stated that R1 was sent to Urgent Care on 5/24/25 with family for an evaluation of the discoloration and for a possible UTI. Later on 5/24/25, following the Urgent Care visit, R1’s family contacted the MCD to inquire about the bruising on R1’s hands. The MCD informed the family that the bruising could be related to R1’s agitation and self-harming behaviors, and also noted that R1 takes medication that may cause the skin to be prone to discoloration. Furthermore, MCD told family that more internal investigation will be conducted as well.

During the course of investigation, the Department conducted interview with Memory Care Director who indicated that R1’s family and responsible parties were contacted regularly regarding resident’s behavior.

Based on interviews and records reviewed the department determined there was insufficient evidence to establish that facility staff failed to notify R1’s authorized representative of R1’s bruising / discoloration or change in condition. Therefore, the allegation is Unsubstantiated.

No deficiencies issues during today’s visit.