Staff informed that R1 was checked on frequently and R1 also pushed their pendent frequently due to their inability to walk independently. Staff noted that R1 tended to slide from their sofa to the floor because they believed they could still walk independently. Staff would place R1 away from the edge of the sofa, place their feet on an ottoman and place a foam mat on the floor in front of the sofa to mitigate them from slipping down and falling to the ground. R1’s doctor and family were aware of R1’s refusals to sleep in their bed. Staff informed that R1 made various accusations about staff, such as swaying them up in the air, placing them on the edges of furniture, and purposely dropping them. The facility added a second caregiver to assist with transfers; this second person also provided a witness due to R1’s claims. The incident in question pertained to an assisted transfer where R1 claimed staff slammed them against the wall. The staff member accused of rough handling, S1, denied handling R1 roughly and affirmed that the proper procedure for transfers was completed for R1 each time. S1 did not observe R1 sustain any injuries during the transfer in question and noted that R1 regularly screamed out in pain during transfers. The second staff member (S2) who was present during the transfer in question denied that S1 physically abused R1. The transfer procedure stated by S2 was consistent with S1’s statements.

Outside sources familiar with R1’s care, OS1 and OS2 were interviewed. OS1 and OS2 informed that R1 suffered chronic pain from an injury sustained over five (5) years ago due to a medical procedure, and that sleeping on the sofa exacerbated it. The outside sources informed that cameras had been placed in R1’s room due to R1’s claims of abuse by staff. The camera footage showed that R1’s statements against staff were not true, and that R1 refused to sleep on their sofa instead of their bed. The sources corroborated staff statements that R1 became angry and resistant with care, which resulted in R1’s care plan being updated to require a second caregiver. The sources informed that the camera footage showed two occasions where R1 slid from their sofa to the floor, possibly attempting to walk. OS2 believed that R1 may have exaggerated the act of the caregivers positioning them toward the back of the sofa to mitigate falls.

A medical professional familiar with R1’s medical condition was interviewed (OS3). OS3 informed that the nature of the allegation that R1 was pushed into a wall would not have caused their hip injury. OS3 informed that R1’s hip condition history, combined with co-morbidities and impact such as a ground-level fall, could have caused the injury.

(Continued on LIC9099 p.3)

R1 was interviewed during the investigation. R1 denied being physically abused by staff, and informed that staff assisted them with ambulation. R1 stated during interview that they had fallen in the past when trying to find water.

Relevant records were reviewed regarding the allegation. R1’s Needs and Services plan reflected R1’s history of falls and goals to mitigate them. Facility documentation showed that R1 hired a private companion, effective 07/18/2025 and additionally received Home Health services for physical therapy. Hospital discharge paperwork on 09/26/2025 and 09/28/2025 showed R1 to have a diagnosis of a hip socket condition and hip fracture with inability to ambulate. Charting notes from March 2025 to September 2025 showed that R1 suffered from chronic leg pain and swelling with hospitalization. The charting notes additionally showed R1’s progression of cognitive impairment decline, as R1 was noted to experience episodes of disorientation, anger/agitation toward staff, and non-compliance with care. Additional notes revealed that R1 suffered unwitnessed falls on 05/20/2025, 05/21/2025, 05/31/2025, 06/04/2025, 06/17/2025, and 07/04/2025. The notes further showed that the facility contacted R1’s primary care physician multiple times regarding R1’s condition, and the facility provided R1 with a reclining chair for leg elevation, however R1 refused to use it. R1 was noted to prefer sitting and sleeping on their sofa. On 09/25/2025 staff documented initiating emergency services for R1 due to leg pain with X-rays requested. On 09/26/2025 R1 returned to the facility with discharge paperwork noting the diagnosis of a hip socket condition and hip socket fracture. Additional health records showed that R1 suffered from chronic swelling of the feet, experienced significant leg pain and did not consistently take their medications. Outside source documentation showed that R1 made claims to healthcare and outside protective agency personnel that staff banged them against the wall, held their legs, and dropped them on their bed.

Medical records and physician statements indicated that at the time R1 alleged to have been physically abused, their hip socket was chronically abnormal, and it would not have taken significant force for their hip to have become partially dislocated. The age of the dislocation remained unclear, and it may have occurred prior to 09/25/2025. The evidence did not definitively show if R1’s injuries were a result of rough handling or a result of some other cause, unrelated to abuse or neglect. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation of staff handling R1 in a rough manner resulting in fracture is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Wes Hebner, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.