complaint·January 18, 2024

The investigation revealed the following. Regarding Allegation(s): Staff handled resident in a rough manner causing injury- It is alleged staff handled resident#1 (R1) in a rough manner causing injury. Five (5) out of the six (6) staff interviewed denied this allegation. Three (3) out of the three (3) residents interviewed denied this allegation. LPA Ramirez reviewed facility staff notes that indicated on 12/10/2023, R1 sustained an injury to R1’s hands and the injury was treated by staff. LPA Ramirez did observe other SIRs indicating R1 having injuries due to unwitnessed falls. LPA Ramirez reviewed nine (9) staff records. LPA Ramirez did observe facility policy on “Adult Abuse” for all staff in staff records. On 12/29/2023, LPA Ramirez received a letter from the facility stating an internal investigation conducted by the facility management did not substantiate this allegation. 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 speaks inappropriately to residents- It is alleged staff speak inappropriately to residents. Five (5) out of the six (6) staff interviewed denied this allegation. Three (3) out of the three (3) residents interviewed denied this allegation. Facility tour conducted by LPA Ramirez on 12/29/2023, did not reveal staff speaking inappropriately to residents. On 12/29/2023, LPA Ramirez received a letter from the facility stating an internal investigation conducted by the facility management did not substantiate this allegation. 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 put resident's mattress on the floor- It is alleged staff put R1’s mattress on the floor. Five (5) out of the six (6) staff interviewed denied this allegation. Three (3) out of the three (3) residents interviewed denied this allegation. On 12/29/2023, LPA Ramirez conducted a tour of R1’s room and upon entry observed R1 sleeping in hospital grade bed. LPA Ramirez observed a large blue fall pad on floor near R1’s bed. LPA Ramirez was told by staff that R1 has that fall pad placed on the floor due to R1 being a fall risk. Fall pad is being used to prevent further injury should R1 have another fall. 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. A copy of this report was provided.