Complaint Investigation Report

9099C-1.. Resident (R1) moved to the community on April 19, 2021 with a primary diagnosis of Dementia and a secondary diagnosis of hypertension, anxiety and depression. (R1) remained ambulatory during their entire stay through October 21,2025 and needed moderate assistance with bathing, dressing, and grooming. The care plan (6/17/2025) additionally notes that (R1) needed maximum assistance with toileting, cognitive tasks such as orientation and redirection, and with staff interventions and care coordination to de-escalate negative behaviors.

Allegation: Staff did not provide adequate supervision, resulting in resident sustaining bruises. The allegation states that staff did not provide adequate supervision, resulting in (R1) sustaining bruises on their arms.

The assessment (6/17/2025) notes that (R1) is independent and doesn’t need any assistance due to not presenting a risk of wandering/elopement but does need moderate ongoing support for disruptive sleep patterns. A family member stated that neither staff nor (R1) are able to state how the bruises occurred. The Administrator stated she was not aware of any bruises and never saw them. When showed the photo, the small circles appeared to be at different stages of healing. The administrator stated (R1) talked to themself a lot and could have bumped into things in their room. Additionally, they could be a side effect of the medication.

On October 2, 2025, a caregiver stated (R1) has "spots on both arms and has had bruises for at least a month", commenting she sees them when (R1) reaches for a cup but didn’t know how the bruises occurred but can "see the decline in (R1’s) face". This care staff stated she has never seen (R1) get physically aggressive with anyone and is "really outgoing with residents, giving them a "high fives", verbally, or fist bumps"; however, (R1) will bump into things in their room. A second caregiver indicated she "does not know about any bruises as (R1) won't let staff shower them, and (R1) has "refused the medication for showers to calm them".

The photos provided to the department showed three small bruises on each fore-arm. The family members stated they think the bruising aligns with fingers. The resident's charting notes reviewed from August 2025 through September 3, 2025 did not document any bruising on (R1's) arms. With showers not being permitted by (R1), staff was not able to do any skin checks.

Based on information obtained, the above allegation is found to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.