complaint·November 12, 2024

On 11/12/2024 at 1:30 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Executive Director, Maria Rivera, to deliver the findings of above allegation. LPA explained the purpose of the visit with Executive Director. During investigation, the Department obtained the following documents from the facility – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, Physicians orders, narrative charting, medication calendar. Allegation: Resident sustained unexplained bruising while in care Investigation Finding: Unsubstantiated On 1/16/2024 and 3/7/2024 the Department interviewed the Reporting Party (RP) who stated that on or around 12/1/2023 had observed bruising to R1s arms and reported it to facility staff. RP did not have knowledge of how the bruising may have happened. On 2/13/2024, the Department interviewed S2, S3, S4, and S5; and on 3/7/2024 interviewed S6, S7, and S8. All staff stated having observed the bruising to R1s arms, but not having specific knowledge as to how it happened – with some reporting that R1 wears her wristwatch and bracelets tightly. S7 further stated that R1s bruising to the arm was “constant” and had observed other residents attempting to assist R1 with getting up from chairs by grabbing R1s arms; and S8 stated having observed R1 hitting herself with spoons. S3 reported that an inconclusive internal investigation was performed. All staff reported that R1 bruises easily. On 2/13/2024, the Department interviewed R1 who exhibited memory issues (confirmed by Physician's Report) and was unable to state what had happened and did not recall the bruising. The Department observed in video supplied by the RP and in facility progress notes that at the subject time, the RP had stated that a group of men had tried to remove her from the facility at night. Progress notes further reflect that the facility was in communication with family regarding the bruising, and unwitnessed falls documented during the subject time period. On 2/13/2024, the Department interviewed W1 who stated having had observed the bruising, discussed the situation with the facility, and knew that an internal investigation was performed. W1 did not believe that R1 had been mistreated by staff. Based on records review, interviews conducted, and observations made, the Department has investigated the above allegation Resident sustained unexplained bruising while in care and found it to be Unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit Interview conducted and a copy of report provided.