complaint·October 21, 2022

Resident sustained unexplained fractures while in care. Resident sustained unexplained bruising while in care. On 3/13/22, at approximately 7:00PM-8:00PM hours, facility care staff discovered dark, purple bruises on R1’s right shoulder, arm and chest while assisting with ADLs. R1 did not complain of pain and did not appear to be in pain. Staff interviews indicated staff are not aware how R1 sustained bruising. On 3/15/22, R1’s family was notified, and R1 was taken to a doctor’s appointment on 3/17/22. Medical records show X-Rays were taken, and R1 sustained two rib fractures of the seventh and eighth ribs, and a torn rotator cuff. Medical records noted the fractures were of indeterminate age. Facility staff was interviewed, and none of the staff had information on how R1 sustained injuries. According to staff, R1 is non-ambulatory and would not be able to get up by herself if sustained a fall. Physician Assistant (PA) who treated R1 was interviewed and indicated based on her medical opinion, there is no way to say how old the fractures were. PA stated it is possible the fractures were old and unrelated to the bruises. R1’s x-rays further indicated R1 has old compression fractures in her spine, which are caused from either severe trauma or Osteopenia. Documents reviewed indicated R1 has Osteopenia which affects bone density. Records indicate R1’s bone density is poor and is at a high fracture risk. This agency has investigated the above listed allegations. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation to be UNSUBSTANTIATED. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of Administrator on these forms acknowledges receipt of these documents.