Complaint Investigation Report

The investigation revealed the following: regarding the allegation “Resident sustained unexplained injury due to staff neglect or abuse.” It is alleged that C1 sustained an injury to their neck due to staff abuse or neglect. Five (5) out of the five (5) staff interviewed denied this allegation. LPA attempted interviews with C1 through C5. Due to documented intellectual disabilities, and because C1 through C5 are nonspeaking or use limited speech, their responses could not be relied upon. During record review of C1’s client files, LPA observed that C1 has a history of skin tears due to C1’s sensitive skin. LPA observed staffing notes and body check logs which indicated in January 2026 and February 2026, staff observed small skin tears on the left side of C1’s neck. Review of C1’s medical care record revealed C1 was treated for a common, benign and self-healing skin condition in older adults, which results in thinning of the skin. Staff sought treatment for C1 in both incidents and C1 was prescribed medication. Staff interviews revealed that C1 has very sensitive skin and C1’s skin will tear and bruise easily. Staff interviews revealed that even medical tape will cause C1 to get a skin tear. Staff interviews revealed that C1 normally rests their head to their left side, which causes skin friction and tears. 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 conducted. No deficiencies were cited for this complaint investigation. A copy of this report was provided.