complaint·January 6, 2026

(Continuation of LIC9099) Interviews with staff reported that S1 contacted Staff #2 (S2) via walkie talkie requesting a medium size bandage. Interviews with S2 and Staff #3 (S3) reported that S2 was unable to assist S1 and S3 was redirected to deliver the bandage to S1. Interview with S2 reported asking S1 of the severity of the injury and was advised by S1 that the injury was minor. Interview with S3 reported that when they delivered the bandage to S1, S3 did not assess the skin tear but noted that they did not observe R1 arm filled with blood like it was reported when Staff #4 (S4) discovered the injury. Interview with S1 reported that after they placed the bandage on R1, S1 continued changing R1’s brief, position R1 into R1’s preferred position in bed, covered R1 with a blanket, and exited the room. Interview with Staff #4 (S4) reported that during their rounds, S4 went into R1’s room to ask R1 if they were ready to go to dinner. S4 went to R1 to uncover the blanket off of R1 and observed R1 to have blood on R1’s right arm, briefs, and blanket. S4 went to Staff #5 (S5) to advise S5 of what they observed and S5 reportedly went to R1’s room to assess R1 then contacted emergency personnel. LPA attempted to interview R1 but interview was unsuccessful as R1 reports that they do not recall how they sustained the injury and suggested that they possibly hit their arm on the bedrail. A records review conducted of R1’s physician report details that R1 is combative at times, requires assistance with repositioning, incontinence care. A review of the residents care plan and assessment details that during brief changes/toileting tasks, R1 requires a two person assist. The assessment and care plan further detail that R1 has complex skin which increases the fragility of the skin. Through observations, LPA observed R1’s bedrails to be equipped with fabric covering and was advised by Staff #6 that the covers were implemented due to R1’s combative behavior as R1 sustained bruising in the past from the bedrail when exhibiting a behavioral episode. LPA further observed R1 to have gauze wrapped around their right forearm region but was unable to view the injury. Due to insufficient evidence, the allegation of resident in care sustained unexplained injury due to staff neglect/lack of supervision is deemed unsubstantiated. A finding that the complaint is deemed unsubstantiated means that although the allegations may have occurred and/or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Through interviews and records review, LPA discovered a health and safety concern. A deficiency will be issued in accordance with Title 22 regulations. A exit interview was conducted and a copy of this report was provided to Executive Director Eva Tawfik.