Complaint Investigation Report

“Resident sustained an injury due to staff neglect or physical abuse.”

It was alleged Resident #1 (R1) was also observed with scratches on the inner part of their arm and a small bruise on their wrist. It is unknown how R1 sustained these injuries. There were no additional details or photos provided of the alleged injuries.

LPA conducted (2) staff interviews with staff who work with R1 12/23/2025 and 12/25/2025. (2) of (2) staff revealed that they did not recalling seeing any injuries on R1’s arm or wrist.

LPA attempted to conducted an interview with R1, however R1 was not alert or oriented during the interview. LPA conducted an interview with R1’s responsible person who reported that they had previously observed scratches on R1’s face.

LPA conducted a random sampling of (6) additional residents who reside in the same building as R1. (6) of (6) residents stated they had no concerns about resident abuse or neglect, and were unaware of any residents being injured on their arms and wrist.

LPA conducted records review of charting notes for R1 from 12/23/2025 to 12/25/2025 and found no charting notes for R1 on those dates. LPA conducted records review and staff interviews which revealed there were no incidents reported for R1 from 12/23/2025 to 12/25/2025.

Therefore, the allegation that R1 had observed scratches and bruises was found to be unsubstantiated.

“Resident left in soiled linens/bed for an extended period.”

It was alleged that on 12/23/2025 and 12/25/2025, R1 was found lying in their bed which was saturated with urine.