complaint·July 9, 2021

During the investigation, it was revealed that R1 had two falls while at a Skilled Nursing Facility (SNF). After discharged from SNF on 2/17/2021, R1 had ongoing issues with a sore to the right toe and swelling of lower right leg. Resident R1 was diagnosed with a tibia fracture on 3/10/2021. When interview R1, R1 was not able to speak to the cause of injury. Administrator Kassia Mitchell reported that R1 is non-verbal at baseline. Administrator Kassia Mitchell stated she was not aware of how R1’s leg was injured. Administrator Kassia stated she had no idea as to what could have caused the fracture and denied any time that R1 fell while in her care. Staff (S1) denied anything occurred that would have caused R1's leg to got injured. Staff (S2) did not know how R1’s injury occurred. Other residents in care that were interviewed did not know how R1’s leg got injured. The investigation revealed the lack of evidence to substantiate that resident R1 was being physically abused while in care. Investigation revealed the cause of R1’s leg injury was unknown. This Department has investigated the complaint alleging the above allegation 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. Exit interview was conducted with Administrator Kassia Mitchell and a copy of the report was provided.