Complaint·August 22, 2025

still ambulatory and walked around and out of the facility without an assistive device. R1’s resident assessments, dated 01/23/2022 and 02/19/2023, both indicated a fall risk service plan with safety checks four times per shift and as needed for R1. A review of the medical records and facility nursing notes revealed that on 05/31/2022, R1 complained of pain in left arm and staff noticed slight swelling in R1’s left wrist. R1’s resident representative was immediately notified and R1 was sent to the hospital for evaluation. According to the medical records, the paramedics stated R1 was pushed off the bed by another resident and fell onto their outstretched arms; patient complained of bilateral wrist pain. X-rays revealed bilateral distal radius fractures. R1 was diagnosed with left and right wrist fractures with no surgery performed. The facility nursing notes, dated 05/31/2022, list “aggressive act victim; R1 noted to have limited range of motion to left arm, slight swelling noted to wrist, hand appears to have no swelling, wrist tender to touch….. Received update from hospital, R1 has fracture to left wrist”. Due to R1’s cognitive impairment, R1 was unable to explain how R1 injured their wrist. On 08/20/2022, R1 fell to the ground when R1 ran into another resident. R1 was evaluated by the facility med tech where R1 initially complained of pain in wrist and arm (nursing notes do not indicate which side). R1 had normal range of motion and stated, “my arm is not broken, if it was, I would be screaming my head off.” R1 was not sent out to the hospital and was treated at the facility with ice packs and monitored. No further complaints of pain were reported. On 11/20/2023, R1 complained of right wrist pain when staff were assisting R1 to get undressed for bed. There was no witnessed fall and R1 was not found on the floor. R1 was assessed and sent to the hospital to be evaluated. During R1’s examination, R1 had x-rays done on both shoulders and right wrist. The left shoulder showed no fractures. The right shoulder showed chronic appearing fractures. The right wrist showed chronic appearing deformity of the distal radius with positive ulnar variances. The bones are demineralized. No acute fracture is seen. The records indicated “chronic injuries that are well healing”. The hospital discharge paperwork, dated 11/21/2023, states “we will discharge the patient home with right wrist and right shoulder fractures which appear to be chronic with a plan for orthopedic follow-up and PCP follow-up”. The 11/21/2023 facility nursing notes revealed the hospital called to give update on R1 and stated R1 seen for right wrist pain had x-ray done on right wrist and shoulder and showed chronic fractures of right wrist and shoulder. An interview with the physician who examined R1 at the hospital on 11/20/2023 was conducted. R1’s x-rays and medical history charts were reviewed. Although R1 did not show any new fractures during the visit, R1 had chronic appearing fractures in R1’s wrists, shoulders and ribs from other past visits. The physician said they could not determine the age of the chronic appearing fractures and they all appeared to be healed or healing. The physician said this and the fact that R1 came to the hospital from an assisted living facility with old trash bags concealed in R1’s pants gave concerns of neglect at the facilit y. The physician spoke with R1’s resident representative who informed the physician it is normal behavior for R1 to conceal items in R1’s clothing and it is part of R1’s diagnosed behavior. R1’s resident representative also told the physician that they believe the staff at the facility treat R1 well and has no concerns for R1’s care at the facility. During the course of the investigation, the Department was informed by R1’s resident representative that R1 suffered two falls before moving into Vista Del Lago, one at a board and care facility where R1 fractured left shoulder and left wrist, and one at home where R1 fractured several ribs. The physician stated that R1’s resident representative did not provide this history to them during their conversation, and it explains many of the chronic appearing fractures R1 showed during his examination. The Department’s investigation revealed facility staff acted appropriately during each incident and advised R1’s resident representative of R1’s condition and obtained R1 needed medical care. Since R1’s return from the hospital on 11/21/2023, staff have been directed to do increased safety checks, home health physical therapy has been ordered and the Resident Services Director said R1’s care plan will be reassessed once R1 is seen by R1’s physician. During the investigation, no evidence or statements were found to corroborate neglect or lack of supervision of R1. Therefore, the allegation is deemed Unsubstantiated at this time. A finding that the complaint 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(s) occurred. Exit interview conducted, copy of this report was reviewed and provide to Marie Hill, Executive Director.