complaint·January 25, 2024

The investigation revealed the following: Regarding Allegation(s): Staff pushed a resident in care - It is alleged staff pushed R1 against wall. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. LPA Ramirez reviewed R1’s facility records and did not observe any documentation of injury from suspected fall or from being pushed. During interview of R1, LPA did not observe any visible injuries. 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. Staff pinched a resident in care- It is alleged facility staff pinches R4. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. LPA Ramirez reviewed R4’s resident record and did not observe any documentation of injury sustained from a pinch or suspected pinch. LPA Ramirez attempted to interview R4 but was unable to due to R4 refusing to answer questions. 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. Staff stomped on a resident in care- It is alleged facility staff stomp on R4. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. LPA Ramirez reviewed R4’s resident record and did not observe any documentation of injury sustained from a stomp or suspected stomp. LPA Ramirez attempted to interview R4 but was unable to due to R4 refusing to answer questions. 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. Staff used foul language towards residents- It is alleged facility staff use foul language against residents in care. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. During tour of facility on 11/13/2023, LPA Ramirez observed staff providing care and supervision to residents. LPA Ramirez did not observe any staff using foul language towards residents. LPA Ramirez reviewed six (6) personnel records and did not observe documentation that staff was reprimanded for use of foul language towards residents. 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. SEE 9099-C for continuation. Staff did not serve a meal to a resident in care- It is alleged staff did not serve R3 a meal due to R3 refusing to change clothing. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. LPA Ramirez toured kitchen on 11/13/2023 and observed sufficient supply of perishables and non-perishables. LPA Ramirez reviewed R3 resident record and did not observe documentation that suggest staff withheld meals to R3. LPA Ramires did not observe documentation that suggest R3 became ill or malnourished due to being denied meals. 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. Staff left resident in the same clothing for a long period of time- It is alleged staff leave R1 in the same clothing for weeks at a time. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. During tour of R1’s room, LPA Ramirez observed multiple sets of clothing in R1 closet and dresser. LPA Ramiez observed R1 to be clean clothing during interview. 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. Staff discouraged a resident from reporting an incident to Law Enforcement- It is alleged staff discouraged a resident from reporting an incident to Law Enforcement. Four (4) out of six (6) staff interviewed deny this allegation. Three (3) out of three (3) residents interviewed deny this allegation. Review of six (6) staff records revealed staff signed Statement of Acknowledgement Requirement to Report Suspected Abuse of Dependent Adults and Elders. 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. Exit interview conducted with Administrator Hernandez and a copy of this report and appeals rights was provided