During the investigation, the LPA interviewed the Administrator, staff, residents, and family members. The Administrator and staff denied the allegations. They stated that staff at the facility have not caused any injury to R1 or any other resident and that staff always provide timely and accurate reports to residents’ representatives. R1 was admitted to the facility on 06/29/25 under Hospice care with a history of skin condition and with a G-tube. Administrator stated that R1 had existing bruises due to prescribed blood-thinning medications that were administered per Hospice orders. The Administrator also stated that R1 had sensitive skin and frequently experienced itching and scratching. According to the Administrator, the itching was a side effect of prescribed medications. The LPA reviewed R1’s file and Hospice documentation, which explained why R1 is prone to bruising easily. The LPA learned that some medications prescribed by the physician may cause itchy skin, rash, and increased or unexplained bruising, making it easier for blood to pool under the skin. LPA also spoke with R1’s responsible party, who maintained regular contact with both R1 and the facility staff. The responsible party explained possible reasons why R1 sustained bruising on their body and skin. The Administrator stated that the facility maintained regular communication with R1’s family members, responsible party, and Hospice regarding R1’s condition. The Hospice nurse was informed and aware of R1’s ongoing scratching behavior. Family members and the responsible party were informed during regular visits. The Administrator, S1 and S2 stated that R1 was repositioned regularly and monitored for skin integrity. Staff also applied Hospice provided cream for R1’s sensitive skin. The Administrator and staff further stated that Hospice was immediately informed of any changes in R1’s condition. Interviewed S1 and S2 stated that they have never observed any staff member handling residents in a manner that could cause harm or bruising. They stated that in the event of any skin condition changes, bruises, lacerations, or skin tears, staff immediately informed the Administrator, who then contacted Hospice for assistance. The LPA interviewed R1’s responsible party (FM1) and FM2. FM1 stated that they visited R1 regularly and were satisfied with the care R1 received at the facility.

Continue 9099C

Based on statements and interviews conducted with staff, residents, and family members, as well as a review of resident and facility records, there was insufficient evidence to support the reported allegations. Although the allegations may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. Therefore, the allegations are determined to be Unsubstantiated.

Exit interview was conducted and the copy of this report was provided to Francisco Moreno.