Complaint Investigation Report

Allegation: Facility staff handled resident in a rough manner resulting in bruising

It is alleged that bruising on both wrists and upper arms that appeared consistent with grab marks from resident #1’s (R1) caregiver.

Based on interviews conducted, four out of six staff and one out of one witness corroborated the allegation. One out of six staff denied the allegation. One out of six staff and one out of one resident could not confirm or deny the allegation. On April 18, 2026, S5 and S6 stated they found the bruises prior to giving R1 a shower. They noticed the bruises and reported to the administrator. S6 stated that they notified R1’s responsible party, when they arrived to the facility on April 18, 2026. S3, S4, S5, and S6 stated that bruises were found on R1’s left and right wrists and upper arms. The bruising was due to caregivers grabbing or holding the resident in a rough manner.

S3 and S6 stated on April 11, 2026, there were no bruise marks on R1, but on April 18, 2026, there were bruise marks evident on R1's left and right wrists and left and right upper arm areas.. S3 stated S1 and S2 admitted to them that they handled the resident in a rough manner which led to the bruising. S1 stated the bruising most likely occurred on April 15, 2026. S1 stated that S1 and S2 attempted to transfer R1 back to bed from the toilet, but R1 was fighting with S1 and S2. In order to prevent a fall or any other incident they needed to hold R1 down on their arms and wrists. Witness #1(W1) stated that the bruises were most likely from April 15, 2026, and that in April, there were no evidence of the bruises prior when they visited on April 18, 2026. W1 stated they were told from a doctor R1 went through a traumatic event because there was evidence of bruises on the left and right wrists and left and right upper arms, and there was evidence of muscle strain on R1’s neck and upper back. W1 stated that the doctor stated the bruising and muscle strains indicate trauma and that R1 was handled a rough manner.

Based on record review, S3 and W1 provided photos of R1 that were taken on April 18, 2026. The bruises are located on both wrists and the upper arms of R1. They are a dark purple color. Medical record dated on April 23, 2026, stated that R1 had bruising on their left and right wrists and upper arms, muscle strain on the neck, and muscle strain on the upper back. Staffing records verified S1 and S2 worked on April 14, 2026, and April 15, 2026, and S6 worked on April 11, 2026, April 12, 2026, April 18, 2026, and April 19, 2026. Based on observation, on May 6, 2026, LPA verified that R1 had bruising on their left and right wrists and upper arm.