Complaint·August 19, 2021

The investigation revealed the following: Regarding the allegation “Resident sustained serious injury while in care resulting in hospitalization. All the parties IB interviewed W1, C1-C3, S1-S3 on 05/17/2021 denied any abuse and stated that R1’s injury was unwitnessed. IB was not able to interview R1 due to R1’s dementia. IB reviewed all hospital medical records did not report suspected neglect or abuse and could find any fault with facility. Regarding the allegation: “Resident sustained many unwitnessed falls while in care”. All the parties IB interviewed on 05/17/2021, 5/17/2021, 5/17/2021 denied any abuse and stated that R1 has sustained unwitnessed falls. IB was not able to interview R1 due to R1’s dementia. IB reviewed records and interviews revealed that R1 needed reminders to call for help with transfers and R1 often tried to transfer alone and had unwitnessed falls. Safety plans and interventions such as physical therapy, bed rails, fall pad and alarm pendant, increase monitoring was agreed on with R1 family to aid in fall prevention. Based on the inform ion obtained and records review R1 has had multiple falls but the facility, family and doctor have fall risk plans in place to prevent falls. Regarding the allegation: “Resident has multiple unexplained scab wounds”. All the parties IB interviewed on 05/17/2021, 5/17/2021, 5/17/2021 denied any abuse and stated that R1’s injury was unwitnessed. IB was not able to interview R1 due to R1’s dementia. IB reviewed records and interviews revealed R1 was ambulated with wheelchair and would sustain accidental bumps, bruised and skin tears from hitting the wheelchair. IB reviewed all medical records from the facility and hospital and could not find evidence of neglect from the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator James Bender, and a hard copy was provided.