complaint·November 10, 2021

Interview on 12/08/2020 with social worker #1 (SC) revealed that resident #1 (R1) had a skin tear in their arm around 06/05/2020. SC continued that staff present at the time did not know what happened and were not cooperative. Review of resident file chart notes on 10/06/2021 revealed that there was no recollection or written statement about a skin tear on R1’s arm. Interviews with staff revealed that R1 started hospice services on 04/28/2020 and was seen frequently by hospice services until R1 moved out of the facility in 06/08/2020. Also, R1 had multiple falls and frequent trips to the hospital between 04/28/2020 and 06/08/2020. Additional interviews revealed that R1 passed away August 2020. Although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is unsubstantiated. Exit interview conducted. A copy of this report provided to Executive Director via email.