Interviews described R1 as frequently wandering into other residents’ rooms, resulting in altercations or confrontations with other residents who may push or strike the resident to protect their space. Staff also reported that R1 had fallen on prior occasions, including tripping over another resident’s walker and requiring medical evaluation. Staff reported ongoing behavioral challenges including hitting, biting, kicking, and attempting to strike staff or other residents throughout the day and evening. It was reported that R1 was receiving medication adjustments due to behavioral concerns, was being closely supervised, and often stayed in areas where staff could monitor them. Staff acknowledged receiving photographs of bruising from the responsible party but stated uncertainty about the cause, stating that R1's wandering, combative behaviors, falls, and interactions with other residents as possible explanations. Interviews further revealed concern for an interaction involving an outside visitor of R1's, which required staff intervention and resulted in changes to visitation. Interview attempts were made with additional staff and outside sources, however, no responses were received back.

A resident familiar with R1 reported that R1 wandered frequently and entered multiple rooms, becoming aggressive at times.

Records review of photographs provided showed a medium sized circular bruise on R1 in an unidentifiable location, other photos showed small circular bruises on R1's arms and other unidentifiable locations. R1's medical assessment revealed a diagnosis of major neurocognitive disorder, confusion/disorientation, wandering, sundowning, and the need for full assistance with ADLs. R1 is noted to have a history of skin conditions or breakdown. The assessment dated 02/24/2026 further revealed R1's frequent agitation, aggression, resistance to care, crying episodes, and declining of showers. No skin issues were noted at that time. A care plan dated 06/16/2026 revealed required assistance with ADLs, skin checks during bathing, and shift safety checks. [Cont. on LIC 9099-C pg. 1]

During the facility visit, the resident was observed lying in bed, well-groomed and appearing asleep. The resident was wearing a long-sleeved shirt no visible bruising or marks were observed at that time. No hazards were observed in the resident’s room.

Based on interviews, and records review, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. An exit interview was conducted with Executive Director Candi Laird and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.