Complaint·May 2, 2023

Investigation Revealed the following. Allegation: Resident sustained injury due to staff neglect Regarding Allegation #1 : Resident sustained injury due to staff neglect. LPA Randle interviewed collateral witness 1(CW1) for complaint. CW1 states that R1 is in hospice care for end stage cancer. CW1 states that hospice staff had seen R1 on 02/14/2023 and there was no injury to the face of R1. CW1 states that collateral witness 2 (CW2) had called CW1 and alleged that facility staff had slapped R1 face. CW1 states that CW1 interviewed R1 who told CW1 that staff had not slapped R1 face and R1 had scratched R1 own face. CW1 states that the injury to R1 face does not look like a hand slap and more like a fingernail scratch. LPA Randle interviewed CW2-CW3 for complaint. CW2-CW3 stated that R1 told them at different times that S1 had slapped R1 face because R1 urinated in R1’s bed. CW2-CW3 stated that R1 has health issues and gets confused easily and makes up stories. LPA Randle received and reviewed color pictures of facial injury to R1 face from CW2. Reviewed color pictures of R1 face with CW1, the skin tear does not appear to come from a slap to the face with open hand and appears more in line with a fingernail scratch due to the age of R1 skin per CW1. LPA Randle interviewed CW4 for complaint. CW4 states that R1 has cognitive issues and makes up stories and gets confused. CW4 states that CW2 also makes up stories believed. LPA Randle interviewed R1 for complaint. R1 states that R1 bumped a wall in R1 room and injured R1 face cheek. R1 states that R1 then scratched R1 face opening the tear. R1 states that no staff member attacked R1 or slapped R1 face. LPA Randle interviewed R2-R6 for complaint. R2-R6 state that residents have never heard of a staff member attacking another resident and that R1 scratched R1 face, and this is how R1 injured R1 face. LPA Randle interviewed S1 for complaint. S1 states that S1 has never attacked or put S1 hands on R1 and R1 scratched R1 face then picked at scar and this is how R1 face was injured. S1 states that no resident or staff ever attacked R1. LPA Randle interviewed S2-S6 for complaint. S2-S6 state that no staff member ever put their hands or slapped R1 face and R1 scratched R1 face, and this is how R1 face was injured. S2-S6 state that they give the best service possible to all residents. LPA Randle reviewed facility file to include needs and service, physician report, hospice records, pre-placement for R1. Records suggest that R1 has cognitive impairment issues, gets confused and makes up stories. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff physically abused resident in care. Allegation: Staff did not notify resident's authorized representatives of incident Regarding Allegation #2 : Staff did not notify resident's authorized representatives of incident . LPA interviewed Administrator ALCARAZ, MONA (S1) denied the allegation. Administrator S1 added that R1’s has no designated POA and R1’s legal representative per R1’s physician report is her husband. S1 states that CW4 visits often usually most days. S1 states that S1 keeps CW4 informed of any issues or changes in condition. LPA interviewed CW4, CW4 stated that S1 keeps him informed of resident R1 condition and that he loved the facility, and the facility cares for R1’s needs. LPA interviewed residents (R2-R7) regarding the allegation Staff did not notify resident's authorized representatives of incidents. Residents interviewed all stated (R2-R7) they had no problem with staff communicating their change of condition or incidents to their authorized representatives. LPA interviewed staff (S2-S6) regarding allegation all stated there were no delays in communicating to authorized representatives of changes to residents’ condition or incidents. Based on information gathered, the department did not find sufficient evidence to support allegation Staff did not notify resident's authorized representatives of incident The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found No evidence to support the allegations: Resident sustained injury due to staff neglect Staff did not notify resident's authorized representatives of incident Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated . An exit interview was conducted with Administrator ALCARAZ, MONA and a hard copy was provided.