complaint·February 27, 2025

Allegation: Staff hit resident in care. In regards to the allegation, it was reported that Resident 1 (R1) has scratches and bruises under the eye and on the body. The reporting party is not sure if these wounds were due to a fall, or abuse by facility staff, as it was also reported that staff slapped R1 in the face. Furthermore, the reporting party stated R1 was alleging that these injuries occurred by the staff member(s). No witnesses were identified, nor staff names were given to these allegations. Interviews made with the staff and Memory Care Director reveal that R1 lost their balance and hit her face on the egress door when trying to awol from the Memory Care Unit to Assistant Leaving Area. At approximately 1:27am on 11/3/2024, R1 was wondering in the memory care hallway, when became very agitated and tried to leave the memory care unit, while S1 tried to stop and redirect R1 back to their room R1 kicked S1 on the left knee, lost their balance and hit their left cheek on the egress door. S1 and S2 directed R1 to their room, first aid was given to R1’s face/cheek area, responsible party and primary doctor were notified. Incident Report (IR) was submitted to the Licensing. Interviews with five (5) of five residents made. All five could not corroborate with the allegations made. Based on the information obtained, there was insufficient evidence to prove that R1 sustained injuries due to staff hit R1. Therefore, this allegation deemed Unsubstantiated . Allegation: Staff pushed resident to the ground It was reported that on 11/4/2024 facility staff pushed resident #1 (R1) to the ground. To investigate this allegation, LPA conducted interviews and record review. Interviews made with four (4) staff members working night shift, revealed that R1 had another episode of aggressive behavior and was trying to awol from the facility. Throughout the night starting at approximately 10:30pm R1 started wondering on the hallways and entering to other resident’s rooms. Multiple times R1 was redirected back to their room, however, minutes later R1 was wondering in hallways again, taking elevator and going down from second floor to first floor. Minutes later R1 entering to room # 127, insisting its their room and refusing to leave. Resident from room #127 asked to take R1 out because its nighttime and wants to sleep. After several attempts to convince R1 to leave from room# 127, staff gently held R1s hand to redirect. R1 got agitated and tried to bite S1. After multiple unsuccessful attempts to convince R1 to go back to their room, R1 decides to stay in the hallway and sit on the bench. S1 and S2 continued with their daily work task by checking residents’ rooms, minutes later alarm turned on from one of the emergency exit egress doors which lead to the back alley of the facility. Continue on LIC9099-C By the time staff reached to the egress door, they found R1 on the floor. Staff called an ambulance and transported R1 to the hospital. Responsible party and primary doctor were notified. Incident Report (IR) submitted to Licensing. Interviews with seven (7) out of nine (9) residents revealed they have never witnessed or heard staff hit or bullied any resident in care. Based on interviews, record reviews and information gathered, there was insufficient evidence to prove that R1 was pushed to the ground by staff member(s). Therefore, this allegation deemed Unsubstantiated . No deficiency issued. Exit interview conducted and copy of this report signed and delivered.