Complaint·October 22, 2024

9099AC-1.. Allegation: Resident sustained unexplained injuries while in care. The allegation states resident (R1) was observed to have multiple bruises on arms and legs at different stages of healing. The House manager stated resident used a wheelchair only, was out of bed part-time and that (R1) moved in with bruises, but she did not document or take any photos of the bruises. Both the House Manager and staff (S1) stated that by the second week, (R1) was able to leave their room and be in the common areas. (S1) stated to LPA on 7/9/24, that (R1) didn't like to be changed, did not fall and never went to the hospital during her three- week stay at the board and care. Resident's family member, the Administrator at the time, and the House Manager also indicated (R1) was never sent to the hospital. A home health staff stated "(R1) did not move in with any bruises", as they saw (R1) at the "initial visit, which was one week after move in" and (R1) only had a small abrasion on her cheek at that time. The home health staff stated they observed bruises on (R1) "two weeks after (R1) moved in", and was told by care staff at that time that (R1) will get up at night and fell. Home Health notes confirm that on 6/10/24 , home health staff observed a "skin abrasion on the right cheek" and that facility staff stated (R1) hit her cheek on her bed when trying to get out of bed during the night. The home health nurse assessed the wound and requested wound care orders. Resident's family member stated that the House Manager would state her staff “were gentle” , but she was told by two home health staff that the bruises were “not consistent with the types of falls the facility said she had” and the bruising was “oval in shape, like a person’s hand-prints. The family member stated the House Manager had told her that (R1) “moved in with the bruises”. Resident's family member stated that (R1) told her there were (2) female caregivers that lived at the care home, and she thinks the one who worked at night is “meaner” based on what (R1) said and that staff "would grab her tight”. Home health notes from 6/17/24 document that a home health nurse was present for wound care, neuro assessment, and a medication reconciliation. Notes document that (R1) is having "hallucinations, agitation and crying, especially during the night". *cont on 9099AC-2... 9099AC-2... Home Health notes from 6/17/24 also document that two home health medical staff observed bruising on resident's bilateral upper extremities. Home health notes from 6/25/24, document that all the bruising appeared to have healed. Resident stated to LPA during an interview that she recalls having a bruise on her face and staff applying creme, but didn't know how it happened. Resident also stated that there were two female staff who worked as caregivers and "one staff was rough and one staff was gentle", especially while being provided incontinent care. Resident showed LPA how when one staff asked her to "turn to the right", her left hand would hit the wall and cause her pain. Resident's record review showed she had a hospital bed with half bed rails that was delivered shortly after she moved in. House Manager stated that resident would resist care being provided and would "fight the caregivers" and bumped her arms and possibly cheek on the rails. Photo documentation of the bruising was not provided to the Department, and there was no evidence that home health staff had contacted the physician to evaluate the bruises. The House manager stated that staff (S2) worked with her for many years and she has observed her to be rough with residents, and (S1) was very sweet and was singing a lot of the time. Based on documentation reviewed and interviews conducted, LPA finds it to be UNSUBSTANTIATED- A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to the Administrator.