complaint·May 29, 2024

LPA observed a photo of the bruising on the back. F1 also indicated on March 13, 2023, F1 was informed R1 had a “rug burn” on their knee and arm/hand. F1 stated they had observed bruises of unknown origin on R1 on previous occasions and noted R1 can be combative. Staff interviewed indicated R1 is “highly agitated.” Staff stated R1 tries to hit, kick, bite, scratch, and spit at other residents and staff. R1 also refuses medications often. Staff stated they have tried having male and female staff assist R1, but R1 “attacks” both and has no gender preference. Staff stated they do not know how R1 got the bruises. Staff stated R1 had not fallen and had not seen a physical altercation to cause the bruises. Staff stated they did not believe any staff, resident, or visit caused the bruises, and staff would not allow that to happen. Staff stated R1 receives the assistance of two staff for Activities of Daily Living (ADLs) including changing clothes, changing brief, showering, brushing teeth, and washing face. Administrator stated after an incident on February 21, 2023, R1 was assessed by a physician who changed their medications and suggested bed rails and a tab alarm on clothing to alert staff to movement. Administrator also stated R1 was put on hospice. R1 did not have a one-on-one staff observing them at all times. LPA reviewed Incident Reports for R1. LPA did not observe any incident reports from around the time the bruise was observed. The investigation did not find sufficient evidence to prove that R1 sustained bruising as a result of staff neglect. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report given.