complaint·November 13, 2024

The investigation revealed the following: Regarding the allegation, “Staff is sexually abusing resident in care.”, it has been alleged that residents are being sexually abused by a staff while being bathed. Record reviews have revealed the following: R1’s Preplacement Appraisal, dated 07/02/2024, indicates "Periods of confusion and disorientation. Short Term Memory Problem." and needs “help with bathing, hair care, personal hygiene.”. Admissions Agreement, dated 07/03/2024, indicates that R1 started living at the facility on 07/03/2024. Physician’s report ( LIC602A ), dated 06/27/2024, indicates that R1 is not “able to bathe self” and is “able to dress/groom self”, with partial supervision and that weekly Registered Nurse ( RN ) visits are required and have been conducted which began on 04/16/2024 lasting through 09/24/2024 and that Mental Condition: (confused/disoriented) is marked as "NO" . LIC602A, dated 09/26/2024: Secondary diagnosis: "Delusional Thought". Weekly RN visits still required. Mild Cognitive Impairment ( MCI ) or Dementia which is checked off as: DEMENTIA . 14a. Mental Condition: (confused/disoriented) is marked as "YE S" . R1’s Appraisal /Needs and Services plan ( ANS ), dated 07/08/2024, indicates that R1: “requires extensive assistance with Activities of Daily Living ( ADL 's) which includes bathing, transfer, grooming and Personal hygiene. R1 has a history of Depression. Mental (Needs): "With short term memory issues" "With periods of confusion and disorientation.". ANS, dated 09/23/2024 indicates that: "R1 was observed with behavioral issues like paranoia, episodes of refusing care, does not want to be touch(ed), R1 claims will get sexually molested. Thinks staff will poison, drug them and contaminate their food. All behaviors reported to hospice and also observe change in resident cognition.". Eight (8) out of forty-two (42) staff were present during an in-service training, which was conducted on 09/23/2024 at 4:00PM, regarding "Dementia, Behavioral Problems, Sexual Harassment, Abuse reporting." which indicates that staff who were present during the in-service training have been made familiar with dementia care, applied behavioral issues, sexual harassment and abuse reporting. Interviews revealed the following: four (4) out of five (5) residents (R2-R5), one (1) witness (W3) and five (5) out of five (5) staff have denied the allegation has taken place. During today’s visit, LPA observed the following: Five (5) out of five (5) Resident(s) were moved out of their beds to the living room (R3-R5). Two (2) residents were transferred via hoyer-lift (R2 & R6), and were also moved to the living room in comfort, via wheelchair. All five (5) Residents (R2-R6) were provided their lunch and feeding assistance was provided via staff five (S5). According to CCLD’s staff record reviews, observations, and interviews conducted, there is not enough evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the above allegation is Unsubstantiated . An exit interview was held with Christina Atencio (S1) and a copy of this report has been provided.