Complaint·May 30, 2023

INVESTIGATIONS REVEALED: Based on records reviews, R1 was admitted to the facility on 2/10/2022. R1 is ambulatory. R1 is self- responsible, able to self-care, able to communicate needs and able to follow instructions. Regarding allegation: Staff injured resident. It was alleged that staff twisted victim's thumb that resulted in an injury. The department interviewed four staff (S1-S4) and six residents (R1-R6). During interviews, it was mentioned that staff twisted R1’s finger in the middle of the night but S1-S4 and R2-R5 denied the allegation that staff injured residents in care. Records review revealed that on 12/3/2022, R1 hit a staff with a cane for intervening in a dispute between R1 and another resident. It was not noted on this incident report that staff hit or injured R1. Based on gathered information, there is no sufficient evidence to corroborate the above allegation. Regarding allegation: Staff made inappropriate comments to resident. It was alleged that a staff called resident a "religious whore" and another staff told resident to kick resident out of the facility if resident reports any abuse." The department interviewed four staff (S1-S4) and six residents (R1-R6). During interviews, it was mentioned that staff made inappropriate comments to R1 but unable to state what staff commented. S1-S4 and R2-R5 denied the allegation that staff made inappropriate comments to residents in care. Based on records review, on 12/5/2022, an incident was reported that R1 asked another resident to help get rid of staff who caused the resident trouble. There is no record of an incident that staff made inappropriate comments to residents. Based on gathered information, there is no sufficient evidence to corroborate the above allegation. This page was amended to revise the report regarding the allegation "Staff did not assist resident in a timely manner. Regarding allegation: Staff did not assist resident in a timely manner. It was alleged that staff did not assist resident in a timely manner when a resident slipped in the bathroom and staff left resident bleeding on the floor. The department interviewed four staff (S1-S4) and six residents (R1-R6). During the interview, R1 stated R1 fell in the bathroom and R1 pulled the emergency pull cord for help but staff did come until an hour later. Then 911 was called. S2 revealed during an interview that about three weeks ago, R1 pulled the emergency cord for help when R1 fell in the bathroom. S2 stated S2 immediately checked on R1 in the bedroom and found R1 out of the bathroom. S2 revealed R1 disclosed to S2 that R1 fell about two to three hours ago and did not pull the emergency cord for help right away. S2 immediately checked R1’s body and found no signs of pain, no bruises, or cuts. S1-S4 and R2-R6 denied the allegation that staff did not assist resident in a timely manner. Based on gathered information, there is no sufficient evidence to corroborate the above allegation. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Administrator Virginia Zenteno and a hard copy was provided.