Per information received from the investigation regarding the allegation that staff handled resident in a rough manner resulting in injuries, the investigation revealed that Resident #1 was taking Eliquis 2.5 mg, a blood thinner. It was also revealed that Resident #1 has dry skin and likes to scratch their hands and also likes to actively move their hands while talking. Per interviews conducted with staff, everyone denies that staff handle residents in a rough manner. Per Staff, they do not pick up residents by their hands. They are picked up by their arm pits. Resident #1 requires a 2 man assist and is picked up by their arm pits so it is unknown how Resident #1 would have sustained the bruises on their hands. The staff also indicated that the residents’ in Safe Haven don't have behaviors resulting in another resident being hit.. The bruises could have been sustained if Resident #1 waved their hands around while talking and could have hit something. Per information provided, Resident #1 likes to hit the underside of the table with their hands or hit the wall and easily sustained bruises due to the use of blood thinner. Per facility documentation dated October 16, 2025, Resident #1’s responsible party was notified of the bruises observed on the top of the resident’s hands on October 15, 2025. The Responsible party expressed concerns. Per facility documentation, staff from each shift who worked on October 14, 2025, were interviewed by the Executive Director. Staff indicated that Resident#1 had been observed laying their head on their hands and scratching their hands. The facility’s Nurse Practitioner was also called, and pictures of the resident’s hands were sent and the Nurse Practitioner indicated that it would not take much pressure to cause bruising due to the use of blood thinner. Per the Executive Director’s interview with Resident #1, they also indicated that the lady who shaves them was also holding their hands, lifted them up by their shirt and lifted them in the air. The lady who shaves the resident is the responsible party. Based on the information obtained from interviews

continued on LIC9099-C

Per information obtained regarding the allegation that staff unable to provide assistance to residents in a timely manner, the investigation reveals that the facility has 3 shifts. Safe Haven has 2 caregivers and a Medication Technician working the morning and evening shift and one caregiver on the night shift. Assisted Living has 2-3 caregivers in the morning and evening shift and one at night. There is a total of 3 staff for the night shift – one caregiver in Assisted Living, one caregiver in Safe Haven and a Medication Technician. The staff assist and cover each other. Per Laura Diaz, Wellness Director, many of the assisted living residents are independent and don’t need assistance with feeding or to be checked regularly. Residents are observed during mealtimes. Room checks are done for at risk residents based on their needs. The Safe Haven residents do not have any issues or behaviors and are asleep and room checks are conducted every hour. Incontinent residents are changed 2-3 times at night or as needed. Per Laura Diaz, they do not have any staffing issues. Staff respond to calls for assistance within ten minutes. Caregivers assist each other if an assigned caregiver is unable to respond to a resident. Another caregiver will provide coverage. Based on information received during the investigation, there is insufficient evidence to support the allegation that staff unable to provide assistance to residents in a timely manner, therefore the allegation is unsubstantiated at this time.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.