complaint·August 27, 2024

Allegation: Staff hit resident. The complaint alleges that on 2/29/2024 four (4) elderly residents disclosed they were been hit "swatted" by caregiver staff (S1). On 3/26/2024, LPA interviewed with translation assistance four (4) Mandarin speaking residents (R1- R4). Three (3) out of the 4 residents allegedly hit denied the allegation. Residents (R1 & R2) were unable to recollect due to cognitive impairment due to Dementia diagnosis. A total of nine (9) residents were interviewed. Resident (R5) stated that caregiver (S1) slapped/hit their legs on numerous times during incontinence care if the resident commented or asked the staff a question. Another resident (R4) was not a victim of abuse, but overheard several residents on different occasions yell for help saying that staff hit them. A total of 9 staff were interviewed. Staff (S1) denied hitting residents. S1 stated that R2 was taken to bathroom to bathe in the middle of the night because the resident had smeared feces on themselves, but the resident pushed away staff and began screaming "Don't hit me". S1 stated that in regards to R5, while providing incontinence care R5 complained of pain in the genitalia area and then the resident moved and their cell phone hit the resident in the head. Staff (S1) denied hitting the resident in the head. The majority of staff reported having no knowledge that S1 was physically abusing residents. However, former Administrator Nelida Arlante conducted an internal investigation, and discovered that staff (S1) hit residents (R2 & R5). In addition, another caregiver (S2) was found to have been physically abusive towards residents. On 3/24/2024, staff (S2) was terminated. LPA attempted to interview S2, but no response was received. Per record review, Administrator immediately suspended staff (S1) on 3/1/2024 and reported it to all required agencies. The San Gabriel Police Department opened an investigation of elder abuse. As of today, Administration staff have not officially terminated staff (S1) because the police department has not provided a copy of the report, but visited the facility last week to inform staff that they closed the investigation. LPA requested investigation findings report from the San Gabriel Police Department, however, a copy of the report has not been furnished. There is sufficient evidence to corroborate the allegation. ***Narrative continues next page. Allegation: Staff restrained resident in care. Information obtained states that staff (S1) tied resident (R2) to their wheelchair with a blanket and told another staff not to untie the resident so that they do not put their hand in their incontinence diaper. A total of 9 residents were interviewed, of which none confirmed the allegation. The investigation revealed that resident (R2) is a Dementia resident whose room was located in the Assisted Living floor, and not the Memory Care Unit. The resident was incontinent and had behaviors such as, taking off their diaper and playing with bowel movements. According to staff interviews, R2 did not have any postural supports physician's orders, but was restrained in effort to prevent incontinence behaviors, and potential falls. Staff (S1) stated that the 2nd floor of the facility has a lot of residents that require total care, and only 2 night shift caregivers responsible for providing care incontinence care and other care as needed. Based on staff interviews conducted the findings indicate that staff (S2) found (R2) restrained to their wheelchair, after S1's night shift ended. Staff (S1) admitted that R2 was restrained because the resident played with their feces. Therefore, there is sufficient evidence to corroborate the allegation. Allegation: Staff handle residents in a rough manner. It is being alleged that staff (S1) handled resident (R5) harshly while providing incontinence care. A total of 9 residents were interviewed, of which 2 residents confirmed that staff (S1) was impatient and yelled at the residents while providing assistance, and often handled the residents very rough. A total of 9 staff were interviewed. Staff (S1) denied mishandling or mistreating the resident(s), and stated they assisted other staff fulfill their care assignments. Staff interviewed stated that the majority of staff treat residents kindly, but sometimes visible bruises were observed on the arms of some residents, which was then reported to supervisors. Based on staff interviews conducted, the findings indicate that staff (S1) handled residents (R1, R3, & R5) in a rough manner while providing incontinence and ADL care. Additionally, S2 was observed on surveillance lifting, shaking, and roughly sitting Memory Care resident (R10) down on their wheelchair. Based on interviews, record review, and photograph evidence it was discovered that staff (S1) has rough handled multiple residents as far back as December 2023. Therefore, there is sufficient evidence to corroborate the allegation. Allegation: Staff do not treat residents with dignity and respect. Concerns were reported that residents were being yelled at and treated in a rude manner. Information obtained revealed that staff (S1 & S2) verbally abused residents by yelling and calling the residents derogatory/teasing names. Staff interviews revealed that 2 regular staff (S1 & S2) and 2 agency staff failed to treat the residents with dignity and respect because sometimes when staff heard the residents screaming or yelling they would simply close the door and ignore the residents. Administrator stated that staff (S2) was terminated on 3/24/2024, due to employee-to-employee altercation, and not mistreatment of residents. Three (3) out of 9 residents reported instances of disrespect. Resident (R3) stated that staff (S1) would yell and spray water in their face or bathe the resident at 1:00 AM. Resident (R5) stated that S1 threw a plush teddy bear at the residents' face and felt "treated like a prisoner". Resident (R8) reported that a staff pushed a resident's wheelchair inappropriately because the resident was shouting. The investigation revealed Administration staff had knowledge of staff misconduct, but the staff in question were not disciplined until after this complaint was filed. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited. An exit interview was conducted and a copy of this report and appeal rights was provided to new facility Administrator Sarah Rafael.