Complaint Investigation Report

***This licensing report supersedes the previous licensing report dated 05/21/26 in order to clarify information obtained during the complaint investigation. The investigation findings will remain the same***

Three (3) of three (3) staff interviewed deny this allegation. Staff stated that staff do not physically abuse or neglect the residents in care. Staff stated they are proactive with the resident’s care and tend to residents’ needs and services daily. Staff stated some residents have unsteady gaits and often bump into furniture and sustained bruises on their person.

Staff stated reporting to R1’s physicians and family of the incidents of severe dizziness and muscle cramps causing R1 to involuntarily cause injury to themselves. Staff stated they escort each resident to the family /activity areas in the morning and assist residents with using their walker and provide walking assistance to residents when needed. Interviews with five (5) of six (6) residents could not corroborate the allegation. Residents stated they are unaware of residents being abused or neglected in the facility. One (1) of six (6) residents stated they are not being neglected or abused by the staff and that the resident is experiencing weakness using the walker and when transferring from bed to wheelchair. The resident stated feeling too weak to walk unassisted and has experienced bruising due to fragility of the skin. Interviews with R1 revealed that R1 is not being neglected or abused by staff. LPA observed R1 had no bruises on R1’s lower leg and left side of R1’s body. Review of R1s medical records show that R1 is prescribed medications that make R1 dizzy and experience muscle fatigue. The majority of R1’s prescribed medications are known to cause dizziness, muscle cramping, and light-headedness, which may contribute to R1 injuring themselves. Review of R1’s physician report dated 03/06/2026, indicates that R1 has history of skin breakdown, and pressure induced deep tissue damage causing bruising to R1. R1’s Primary Physician is aware of R1’s physical condition and R1’s susceptibility to weakness and dizziness caused by the interactions of R1’s prescribed medications, which have led to R1 striking a surface and bruising to R1. R1 is not receiving Home Health services, due to R1’s family stopping R1’s Home Health services as of 04/09/2026. The investigation did not reveal that staff are neglecting and/or physically abusing residents in care.

Based on records review and interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was held and copy of this report was provided to the Administrator, Barbara Bioston.