complaint·March 5, 2026

During today's visit, LPA Konishi obtained the following documents: staff and resident rosters. The investigation revealed the following: in regard to the allegation, “Staff neglect resulted in resident's unexplained fracture while in care.” It is alleged that R1 sustained a bruise on the right leg and diagnosed with a fracture. This allegation was investigated by the Investigation Bureau (IB) and was assigned to Investigator Miles. LPAs reviewed IB interviews which revealed the following: On 06/10/2025, the day of discovered unexplained injuries, Witness #1 (W1) conducted a regular caregiver visit with R1 at the facility and observed swelling and a dark bruise to R1’s right leg. W1 reported and photographed the unexplained injury to R1’s family member and facility staff. The Administrator and two (2) out of two (2) staff interviewed were unable to provide any information about how R1 obtained the unexplained dark bruise and swelling on the right leg. On 06/14/2025, family member contacted 911 and R1 was transported to the hospital, where R1 presented a “right lower extremity swelling and was found to have a right tibial fracture and deep vein thrombosis (DVT/blood clot).” Per record review, it was observed that R1 was attended to daily by Home Health aides and facility staff. The cause of the fracture is unknown as there were no reported falls and staff interviewed were not sure how or when the injury occurred. Because the mechanism and timing of the injury are unclear, the Department is unable to substantiate that the injury occurred due to facility neglect or lack of care and supervision. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of residents’ files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was held, and a copy of this report was provided to the Administrator, Monica Aguilera.