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32 | [Cont. from LIC 9099]
Regarding the allegations, interviews with staff revealed that R1 frequently wears long sleeves or a robe, is a fall risk, ambulatory throughout the facility, and at times confused. Staff revealed that R1 may refuse assistance, wander, and can swing their arms when agitated. Staff stated that R1 does not call for help, and prefers independence, R1 will instead stay near common areas often. Interviews consistently stated they did not witness any incident in which R1 was handled roughly or physically harmed. Staff reported that when asked about the bruise, R1 provided differing accounts such as being “pulled” or “pinched,” but became emotional, confused, and unwilling to provide further details such as a name for who may have harmed R1. Interviews further reported that R1 has had bruising or skin issues in the past. Staff stated they respond to call systems within minutes unless assisting another resident, and that R1 rarely uses the call system due to their desire for independence.
Interviews residents revealed concerns primarily related to occasional raised voices or communication style among staff, but none reported witnessing any rough physical treatment or abuse. Residents stated staff respond promptly when assistance is requested. Residents described the environment as sometimes tense due to language barriers or impatience but did not report or observe physical mistreatment.
During an interview with R1, confusion was exhibited and recollection was inconsistent. R1 minimized the incident and repeatedly stated that no one caused harm. R1 alternated between describing accidental contact with an object and refusing to discuss the matter further, stating that the situation was “no big deal.” R1 remained consistent in denying injury caused by staff.
LPA observed R1 clean and well-groomed. Bruising was observed on R1’s right forearm, red-purple in color. No hazards or environmental concerns were present in R1’s room or the facility.
Record review showed documentation of R1 experiencing both calm and agitated days throughout July of 2026, including resistance to care, confusion, and slamming of drawers. Medical assessment records show R1 has mild cognitive impairment, anxiety, and chronic medical conditions. R1 is identified as a fall risk with prior fall history. Appraisal records show memory loss, forgetfulness, sporadic anxiety, wandering behaviors, and the need for redirection.
Based on interviews, and records review, the preponderance of evidence standard has not been met, therefore the above allegations are found to be unsubstantiated. An exit interview was conducted with Licensee Gus Fernandez and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided. Their signature confirms receipts of these documents.
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