complaint·March 5, 2026

A review of records revealed that R1’s Physician Report with exam date of 08/15/2024, indicated cognitive impairment, dementia, confusion, and disorientation. The Physician’s Report, under category Able to Communicate Needs, it reads “unknown.” Facility charting notes were reviewed. The charting note dated 04/21/2025 revealed R1 was found on the floor in the hallway. Caregiver reports that R1 stated they did not hit their head and R1 was not complaining of pain or discomfort. Charting note dated 04/22/2025 revealed R1 was their normal self and was not complaining of pain or discomfort. Charting note dated 04/23/2025 revealed there were no complaints of pain or discomfort. Charting note dated 04/26/2025 revealed staff noted discoloration on R1’s left arm. The note further reads there no reports of R1 falling. This note has a time of 12:21pm. The next charting note dated 04/26/2025 with a time of 3pm, read R1’s arm was swollen and bruised and R1 was sent to the hospital. An interview with medical staff who responded to the facility, reported that during their assessment of R1’s injuries, they observed bruising and swelling on the left arm. It was described as a purple and green bruise starting on the left arm, extending to the bicep, elbow and chest area of R1. The medical staff further reported R1 complained of pain but due to their cognitive condition, R1 could not explain what happened. They added that during checks for movement, R1 could not use their arm. Based on their medical experience, the injuries appeared to have occurred a couple of days prior, based on how much bruising was sustained. R1’s medical records dated 04/26/2025 were reviewed, which revealed R1 was seen for an upper extremity injury. Medical records revealed a diagnosis of humeral fracture, possible c-spine fracture. Therefore, the allegation is SUBSTANTIATED, which means the preponderance of evidence standard has been met. A copy of this report along with 9099D, and Appeal Rights were provided to Executive Director, Barbara Bogoje. An interview with the Executive Director, Barbara Bogoje, she reports there is not a policy on timely checks. She further reported that checks should be done every one to two hours. The Executive Director explained that caregivers do not document these checks. Interviews with caregivers revealed they check on residents every hour to hour and a half. Records were reviewed. A review of R1’s Needs and Services Plan, with an effective date of 08/15/2024 was completed. The review revealed the plan was not signed by neither the resident, the resident’s responsible party nor a facility representative. The review of this document revealed relevant information under various categories. Under the category of Activities of Daily Living, it reads “Independent” and the note reads “uses walker outside of building”; under the category of Falls, it reads “No”; under the category of Ambulation, it reads “Independent”. A review of R1’s Physician Report with exam date of 08/15/2024, revealed R1 was able to independently transfer to and from the bed and was considered ambulatory for purposes of a fire clearance. The investigation did not reveal that R1 was a fall risk or was on increased supervision checks. Therefore, the allegation is unsubstantiated, meaning the preponderance of evidence standard has not been met. A copy of this report was explained and provided to Executive Director, Barbara Bogoje.