Staff interviews further revealed that staff were unaware of the approximate twenty-five (25) red/purple marks on R1's arms and hands due to R1 typically wearing long sleeves covering their arms. Staff interviews revealed a gap in time of approximately two (2) months where written care notes were not documented for R1.

Review of facility care notes for R1 showed a break in documentation from 12/14/2023 to 02/13/2024 where changes in R1's condition were not documented. On 02/14/2024 the documentation resumed, noting bilateral marks observed on R1's upper extremities. The documentation did not speak to any changes of behavior for R1 that precipitated the marks, what may have caused the marks, action taken by the facility to assist R1 with medical care for the marks, or notification to R1's primary care physician regarding the marks. The investigation did not produce consistent shower log documentation to show that the marks on R1 had been observed by staff. R1's Care Plan dated 12/10/2023, during the timeframe of concern, reflected that R1 was a fall risk due to vision impairment and required the use of their walker as a mobility aid. The Care Plan further noted that R1 required escorts to and from activities and the dining room daily. Pertaining to skin issues, the Care Plan listed, "Excessive Dryness" only as a skin condition. The Care Plan did not account for staff's knowledge of R1 being prone to bumping into objects or care to be provided to mitigate this. Records were not found to show that the facility communicated the marks on R1's arms and hands to their primary care doctor, or that staff attempted to evaluate the condition. No documentation was found to show that R1 was receiving Hospice services during the timeframe of concern.

An interview was conducted with an outside source familiar with R1’s care and needs. Regarding the marks in question, the outside source stated they themselves determined the condition of the marks and they did not have R1 evaluated by a physician because the outside source had a medical background. The outside source informed that R1 had exhibited violent and aggressive behaviors with them, pushing and hitting the outside source, as well as practitioners during routine appointments. The outside source expressed concern that R1 was being physically abused at the facility, however no evidence provided confirmed that the claim was valid.

Photos of R1's arms and hands during the timeframe of concern showed approximately twenty-five (25) dime and quarter-sized round marks along both of R1's upper extremities. The marks were shown to be purple, red, and brown in color. (Continued on LIC9099 p.3)

The staff failed to report R1’s bruises, and no action was taken by management to determine if R1 would benefit from additional services to meet their needs and avoid further injury. Management completed three resident assessments and service plans dated 12/10/23, 03/26/24, and 05/03/24 to determine the level of care R1 may require. Administration completed the assessments in which R1 continued to be evaluated between level one and level two care plans. The care plan indicated that R1 required staff to assist them walking to meals and activities as well as other basic daily tasks.

Due to the lack of information provided by facility administration and staff regarding the bruises on R1, this indicated a lack of care and supervision. The facility administration failed to recognize the change in condition for R1 and did not initiate an overall medical assessment to ensure their safety and well-being. Therefore, the allegation of Neglect/Lack of Care and Supervision of resident R1, who sustained egregious bruising that went unnoticed and undocumented by staff, provides enough information to support the allegation.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Mark Ranno, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.