complaint·August 21, 2025

9099C-1.. Allegation: Staff inappropriately handled resident resulting in resident sustaining fracture. The allegation states after resident (R1) vomited in the dining room, staff (S1) came to assist and grabbed (R1's) arm and yanked it and (R1) has had pain in their arm since this incident. (R1) requested to be sent to the hospital on 3/12/2025 due to experiencing weakness, pain in their right hand and a cold. Documentation reviewed shows (R1) was sent to the Emergency Room on 3/12/25 for the chief complaint of weakness and right hand pain. An x-ray revealed (R1) had a possible distal and radial ulnar fractures. Facility records, specifically the physician's report, showed that resident had a prior diagnosis of rheumatoid arthritis and osteoporosis. (R1) indicated they threw up in the dining room, but the Department was not provided with a specific date for this incident. The Administrator stated this incident occurred late January or early February 2025. (R1) stated that staff (S1) "responded to assist resident and grabbed their arm, ignoring resident's request to let go due to it causing them pain. (S1) denied grabbing or pulling on resident's arm, or physically abusing (R1) at any time,insisting she only "lightly touched" (R1's) hand. (S1) stated she was about to wipe resident's hand when (R1) told her to stop and she let go. The Administrator indicated (S1) went to get some wipes to assist (R1) and her touch was "very mild" when wiping (R1's) hand. Another resident (R2), witnessed the incident, and her statements corroborated with (S1's) statements. Additionally (R2) stated they did not feel (R1) was physically abused or mistreated. The Executive Director/Administrator confirmed that staff (S1) did not have any prior complaints from other residents or staff. The Administrator explained that resident (R1) also did not report the suspected physical abuse until a month had passed and it was reported following a separate incident between (S1) and (R1) where (R1) felt (S1) had offended them by a comment she made. It was unknown how or when (R1) sustained the injury. Based on information obtained, the allegation is found 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. *cont on 9099C-2.. 9099C -2... During the interview process of the investigation, the Department received the following additional information that is unrelated to the allegation in this report, as follows: Resident (R1) reported that staff, (S3) and (S4) were verbally abusive to them and staff (S4) grabbed their right arm. No other details provided. LPA interviewed staff (S3) and (S4) who stated that they would both assist (R1) with repositioning in their bed. Both staff stated that (R1) would sometimes refuse assistance and staff would not force (R1) since it's right to refuse. One staff stated they would let (R1) take their time and assist when they were ready for staff to help Both staff denied being verbally abusive to (R1) and said (R1) had moments where they "would be irritated" with staff and observed (R1) to be rude to many other staff. Both staff indicated they never grabbed (R1's) arm or saw any other staff do so. Based on information obtained, there was insufficient evidence to prove by a preponderance that this occurred. Resident, (R3), stated client (R4's) clothing and jewelry have been stolen. No details or dates of missing items were provided, but the incidents were allegedly reported to an unidentified facility staff but nothing has been done about it. (R3) indicated that (R4's) health has declined over the last 3 years and was not sure if this was related to the missing items. The Administrator stated on 8/21/25 that (R4) reported a missing shell sweater to her and that she found the missing item in (R4's) closet, which was stuffed, and took a picture and showed (R4). The Administrator was not aware of any other items belonging to (R4) that were reported missing. Staff (S3) stated that (R4) resides in a different building than where she or (S4) is assigned. The administrator confirmed the facility is following their theft and loss policy and logging items when they are reported missing. Based on information obtained, there was insufficient evidence to prove by a preponderance that this occurred.