complaint·January 23, 2026

. . . Continued from LIC 9099 On 10/15/2025, a physician specializing in orthopedics examined R1 and reviewed X-rays that revealed a minimally displaced long oblique/spiral fracture of the distal ulnar shaft. The specialist explained that such fractures are usually caused by direct impact, though twisting could not be ruled out. He stated that the injury was not a major cause of concern for possible abuse and appeared instead to be a "common" type of injury due to R1's osteoporosis. This was because R1 had osteoporosis, and the injury could have occurred if she hit her arm on something, or if her arm was caught in the hospital bed and R1 twisted her arm in an attempt to “get free” from the hospital bed. The daughter reported she has never observed staff handling R1 in a rough manner. Staff interviewed stated they always assist R1 by supporting her under the armpits during transfers from bed to wheelchair and have never pulled her arms. The resident’s room is equipped with a motion sensor and a bed alarm that alerts caregivers when R1 attempts to get out of bed, and caregivers have not witnessed any falls. In October, R1 began sleeping in a hospital bed with safety rails. On one occasion, staff observed that her arm appeared to be stuck in the bed rails, as if she had “tangled herself” in the safety railings of her bed. No further issues with the bed railings have been observed since then. According to interviews, review of facility records and video tapes, and a review of R1’s medical records, there was no indication that R1 was handled in a rough manner by staff causing a fracture. The data analyzed does not support the allegation. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED . Exit interview conducted and a copy of this report was provided.