complaint·May 13, 2021

from the resident's cat. Hospice medical records revealed skin tears and bruising was observed on R1; however, no suspicion of abuse was documented. Therefore, due to lack of information, this allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation, "Facility staff are verbally abusive toward resident," it was alleged facility staff would yell at and speak authoritatively to R1, causing the resident to feel belittled. R1 could not be reached for an interview. The ED was interviewed and reported having no information on the allegation. Resident interviews were conducted, and no concerns of verbal abused were reported. Therefore, due to lack of information, this allegation is deemed UNSUBSTANTIATED at this time. 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 violations occurred. An exit interview was conducted with ED Crockem; this report was reviewed, and a copy provided, along with LIC 811. times of instances in which contact could not be made or when messages were left. Facility Progress Notes record multiple dates in which staff contacted one of R1's responsible parties. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation, "Facility staff did not regularly inform resident's representative of health changes," it was alleged R1's declining health led to multiple falls in December 2020 and staff failed to report the health change to the resident's responsible party. The LPA initiated the investigation on December 31, 2020. According to ED, Crockem, R1 did sustain multiple falls, which were caused by the resident's pet cat. Crockem reported R1's responsible party refused to have the pet removed. Records review was conducted, documentation of the request was not observed on file. Staff interviews were conducted; it was reported R1's responsible parties would be notified of falls R1 sustained. Staff also reported R1's falls were caused by the pet cat. Progress Notes from December 2020 were obtained; documentation of calls to the responsible party was observed on file. Therefore, this allegation is deemed UNSUBSTANTIATED at this time. Pertaining to the allegation, "Facility staff did not provide adequate food service to resident," it was alleged R1 would be served small meal portions and, on occasion, staff would forget to deliver food resulting in R1 going without a meal. ED, Crockem, stated she had no information on the allegation. R1 could not be reached for an interview. A records review was conducted; a Comprehensive Nursing Assessment from Hospice, dated December 14, 2020, revealed R1 gained three (3) pounds since their admission, in January 2020. Staff and resident interviews were conducted; it was reported R1 would regularly receive meals and did not make complaints about not receiving enough food. It was also reported by residents there are no concerns with food service at the facility. Therefore, based on a lack of information, this allegation is deemed UNSUBSTANTIATED at this time. With regard to the allegation, "Facility staff caused injuries to resident," it was alleged R1 sustained a skin tear, in or around April 2020, due to an unknown staff member hastily zipping up compression stockings on the resident. It was also alleged R1 sustained bruises, in or around May 2020, due to being aggressively handled when given bathes. R1 was not available to be interviewed. The ED was interviewed and reported R1 did utilize compression stockings; however, she indicated the only injuries R1 sustained were due to the resident's pet cat scratching their legs. The ED denied R1 sustained injuries due to staff abuse. Staff assigned to care for R1 were interviewed; no suspicions of or known abuse was reported. Interviews reported skin tears and bruises were observed on the resident; the injuries were believed to be caused by falls and scratches conducted; it was reported R1 was observed to be in pain and facility staff were not administering the needed dosages of medication to R1. Furthermore, the facility eMAR indicated one (1) medication appeared not to have been administered on December 17, 2020 and December 18, 2020. Therefore, based on records review, this allegation is deemed SUBSTANTIATED. Regarding the allegation, "Facility staff did not clean resident's bedroom," it was alleged the litter box of the cat belonging to R1 was observed on December 07, 2020 to be overflowing in the resident's bedroom and the room was dusty and dirty. R1 could not be reached for an interview. Photographs of R1's bedroom were obtained. Staff interviews reported the kitty litter was cleaned out regularly and room maintained clean. Third party interviews were conducted; one (1) report was received indicating R1's bedroom was observed to be dirty. Therefore, based on photographs and interview, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted with ED Crockem; this report was reviewed, and a copy provided, along with LIC 811 and Appeal Rights.