complaint·January 16, 2025

Another staff member observed this same bruising on R1's left hip on 8/1. On 8/6 at 3:07 a.m., R1 was trying to use their wheelchair as a walker in the hallway, and while a staff member (S18) attempted to redirect R1, R1 stood up and lost balance. R1 "gradually fell down as their hand was holding into the railing," according to S18’s note. R1 did not hit their head, but felt pain in their left arm. R1 suffered a skin tear on their elbow. First aid was provided. A few hours later, at 6:57 p.m., S8 noted R1 had a "big purple bruise on their neck." S8 made a second note at 8:48 p.m., noting that the bruise was bigger and R1 was feeling pain in their left arm. On 8/10, S15 observed "a lot of bruises" on R1's neck down to their left breast, and a bruise on their left hip. Ongoing progress notes for R1 also describe the appearance of bruises on R1's neck and chest between 8/6 and 8/10. On 8/18, R1 suffered an unwitnessed fall while attempting to transfer from bed to their wheelchair. R1 was sent to the hospital. LPA Moleski reviewed an incident report for R1's fall on 8/18/24. According to the incident report, R1 was attempting to transfer from bed to their wheelchair when R1 fell, and later complained of hip pain. R1 was admitted to a hospital for a hip fracture, and was transferred to skilled nursing afterward, per the incident report. LPA Moleski reviewed video footage of this fall, and observed that staff promptly responded to R1. None of the 18 staff members interviewed had observed caregivers of this facility committing any acts of abuse or any acts of neglect resulting in injuries to any residents. In an interview with S18, the caregiver present for R1’s fall on 8/6/24, S18 said that R1 did not hit their neck, face, chest, or head, and had no explanation for the bruises later observed on R1. Several other staff members observed the bruises on R1’s neck described in the notes from 8/6/24, but none were aware of the precise cause of the injury. None of the 18 staff members interviewed voiced any significant concerns for R1’s care at this facility. In an interview, R1 said they were well taken care of at this facility. Assessments from prior to R1's hospitalization indicate R1 was able to independently use their walker and transfer themselves. The department has determined the following as it relates to the allegations that a resident suffered injuries due to staff neglect: Based on interviews, observation and record review, the above allegation is UNSUBSTANTIATED, which 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. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Revera.