Complaint·February 27, 2025

Investigation revealed the following: Allegation: Staff did not prevent resident from being physically assaulted at the facility It is being alleged that R1 has been chronically abuse by staff for “years” and physically assaulted by a resident. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 assures the department that she has looked into the allegation, and it is not true. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed (6 ) out of (6 ) denied abusing R1 or any other resident. (6) out of (6) stated that they have never witnessed any other staff abusing R1 or any other resident. Additionally, (6) out of ( 6 ) staff stated that they have never witness R1 being physically assaulted by another resident. On 2/27/25 the Department interviews (R1-R6). Of those interviewed, (5) out of (6 ) stated that they have never been assaulted by staff or another resident. (1) out of (6) stated that they have been physically assaulted by staff and a resident. On 2/27/25 the department reviewed R1’s file and found that there have been no incident reports of physical abuse by staff nor resident. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff stole resident's personal property. It is being alleged that staff has stolen “a lot” of R1’s clothing and other “necessities.” On 2/27/25 the Department interviewed (A1) regarding the allegation above. page 2 of 6 A1 stated that there is no evidence of any staff stealing from residents. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed (6) out of (6) stated that they have never stolen anything from a resident and haven’t witness any other staff stealing from a resident. The department conducted interviews with (R1-R6). Of those interviewed (5) out of (6) stated that staff have never stolen anything from them. (1) out of (6) stated that staff has stolen personal property from them. On 2/27/25 the department reviewed R1’s file and found that there have been no incident reports of theft committed by staff as indicated in the complaint. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff did not ensure the facility was kept free of pests It is being alleged that the facility has roaches and bed bugs. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that there has been no issues of bedbug or roaches in facility that the facility gets fumigated, and the maintenance worker sprays the rooms frequently as a preventative measure. Additionally, housekeeping staff frequently check for bugs due to some residents eating in their rooms which may cause roaches to appear. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed (5) out of (6 ) denied that the facility has roaches and bedbugs. (1) out of (6) stated that they have roaches and bedbugs sometimes, but it is taken care of in a timely manner. The department conducted interviews with (R1-R6). Of those interviewed (5) out of (6) stated that they have not seen a roach or a bedbug and denied having been bitten by a bedbug (1) out of (6) stated that the facility is full of roaches and bedbugs and states that she has been bitten by a bedbug while at the facility. Based on the information gathered, there is insufficient evidence to support the stated allegation. Page 3 of 6 Allegation: Staff did not prevent resident from destroying another resident's property. It is being alleged that a resident has broken R1’s entry door “10 times,” broke “7 televisions.” On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that a resident and another resident frequently have altercations with each other and one of them tends to break things to blame the other to “get her in trouble.” A1 further stated that repairs are done timely to fix items that are broken. On 2/27/25, the Department conducted interviews with (S1-S6), of those interviewed (4) out of (6 ) stated that there is some property destruction. (2) out of (6) have never witness property destruction. The department conducted interviews with (R1-R6). Of those interviewed (5) out of (6) stated that they do not know anything about a broken TV or a broken door. (1) out of (6) stated that there is major property destruction caused by a resident at the facility. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff did not allow resident to access facility common areas . It is being alleged that staff won’t let R1 eat in the dining room. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that no one is restricted from common areas, however when a resident is causing a disruption, they are told that they have to calm down or leave the area. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed (5) out of (6 ) stated that no resident is restricted from a common area however one resident who is disruptive have been asked to leave the area unless she calms down. The department conducted interviews with (R1-R6). Of those interviewed (5) out of (6) stated that no resident is asked to leave a common area or is not allowed to be there. (1) out of (6) stated that she is band from the dining area. Based on the information gathered, there is insufficient evidence to support Page 4 of 6 the stated allegation. Allegation: Knives were made accessible to residents in care It is being alleged that R1 has been chased with knives in the facility by another resident. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that residents don’t have access to knives in the facility, however on occasion a resident would bring something into the facility that is not allowed. On one occasion a resident did have a knife but it was immediately confiscated once discovered. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed ( 5 ) out of ( 6 ) stated that they have never witnessed a resident in possession of a knife. The department conducted interviews with (R1-R6). Of those interviewed (5 ) out of (6) stated that they have never seen another resident with a knife. (1) out of (6) stated that they have seen another resident with a knife and she was chase by the resident with the knife. On 2/27/25 the department observed the kitchen area during facility walkthrough and found that the knives are inaccessible to residents in care. The knives are locked in an area where residents do not have access to. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Facility is in disrepair . It is being alleged that there was no working elevator in the facility for 1 ½ years. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that the elevator is working, however about a year ago, the elevator was not work. A1 further stated that the elevator is maintained on a regular basis. On 2/27/25, the Department conducted interviews with (S1-S6), of those interviewed (6 ) out of ( 6 ) stated that the elevator has been working properly. The department conducted interviews with (R1-R6). Of those interviewed (5 ) out of (6) stated that the elevator has been working consistently. (1) out of (6) stated that the elevator is always broken. Based on the information gathered, there is insufficient evidence to support the stated allegation. Page 5 of 6 Allegation: Staff made resident deliver food to other residents. It is being alleged that R1 is being used to deliver food to other residents. On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 stated that no resident is allowed to bring another resident food, that is the staff’s job. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed (5) out of ( 6 ) stated that they have not witness a resident taking food to another resident. The department conducted interviews with (R1-R6). Of those interviewed (5) out of (6) stated that no resident takes food to another resident. (1) out of (6) stated that she is asked to take food to other residents. Based on the information gathered, there is insufficient evidence to support the stated allegation. Allegation: Staff spoke inappropriately to resident in care. It is alleged that R1 is “constantly humiliated, screamed at and threatened.” On 2/27/25 the Department interviewed (A1) regarding the allegation above. A1 denied above allegation. On 2/27/25 the Department conducted interviews with (S1-S6), of those interviewed ( 6 ) out of (6 ) stated that that they have never humiliated, screamed or threatened a resident in care. The department conducted interviews with (R1-R6). Of those interviewed ( 5 ) out of (6) stated that they have never been humiliated, screamed at or threatened by staff. (1 ) out of (6) stated that she is always humiliated, screamed at and threatened by staff. Based on the information gathered, there is insufficient evidence to support the stated allegation. Although the allegations above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are UNSUBSTANTIATED. No deficiencies were cited for the above allegations. Exit interview was conducted. A copy of this report was provided to Cecilia Torres, Assistant Administrator Page 6 of 6