complaint·December 22, 2025

9099C-1. Allegation: Staff hit resident. The allegation states that staff (S1) was observed to hit resident (R1) on/around mid-September 2025 while staff was pushing resident back to their room. The allegation states that when (R1) became agitated, staff (S1) became frustrated and hit (R1) in the shoulder. The facility submitted a Report of Suspected Dependent Adult/Elder Abuse (SOC341) to the Department on September 12, 2025. The SOC341 states that on September 6, 2025 (approximately 5:00 pm), a family member observed (R1) to be having an aggressive behavior during dinner time and hit staff (S1). The report states that (R1) was hit on the back on the left shoulder by (S1), who then took (R1) back to their room, stating to (R1) they had to go back to their room. The report notes the Ombudsman's office was also notified of the alleged incident by fax. The administrator stated on October 15, 2025 that (S1) was suspended accordingly and following their internal investigation, it was determined that the alleged incident did not occur and (S1) was allowed to return to work. LPA interviewed (S1) who was adamant they did not hit (R1) and this is a "false claim". (S1) explained (R1) started to get angry when they were sitting in their wheelchair in the dining room because one of the caregivers stated (R1) is "not supposed to be in the dining room due to being infected" with something contagious. (S1) stated when they tried to take (R1) in their wheelchair back to their room (R1) then " tried to hit" them, and a Med-Tech arrived to assist and was able to calm (R1) down. (S1) stated he and staff, (S2)were the only staff present when (R1) became agitated, prior to the Med-Tech arriving and confirmed they "did not hit the resident (R1) back" explaining they "can't do that" and fully is aware of that. (S1) described (R1) to be "shaking in his wheelchair, with uncontrolled movements". (S1) stated they had the next two days off from work, but when returning, they "had to be reassigned to the other side" of the facility where (R1) does not reside. (S2) stated to LPA she did recall being in the dining room on September 6, 2025, around dinner time, and did not observe either (R1) hit (S1) or (S1) hit (R1). Charting notes for (R1) do not document anything information about the alleged incident; however, the notes reflect that (R1) was "very agitated" with staff on the following day around 11:30 pm. (R1) moved to a higher level of care on October 20, 2025 and was not able to be interviewed. *cont on 9099C-2.. 9099C-2... Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid- there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff do not provide adequate food service. The allegation states residents will complain about being hungry, but staff will not provide any snacks in between breakfast and lunch and lunch and dinner. The administrator stated the facility serves snacks, between meals and there is a snack cart, with fruit and sandwiches, that is wheeled around during activities. She explained that snacks are left in the kitchen and staff will get them if a resident asks and that some family members will bring snacks in that are kept in the Medication Room. LPA spoke to a Med-Tech and observed snacks for (2) residents to be stored in the medication room on December 22, 2025. The RCC stated on December 4, 2025 that some residents go to bed after dinner and some residents request snacks, explaining the caregivers make sure the Med-Techs are also nearby to assist residents with snacks. The RCC stated snacks are offered such as crackers, yogurt, Ensure drinks, and a "lot of fruit" and expressed she has "not ever seen snacks run out", and "many families will send snacks" for residents which are kept in boxes in the medication room. The RCC confirmed care staff are familiar with which residents have snacks stored on site. (4) care staff were interviewed. One staff stated snacks offered at the "pm" time are "small snacks"- and consist of "cookies, fruit, bananas, strawberries, mango" and confirmed staff will serve snacks to residents "wherever they are"- in their rooms or in the dining room or common area. This staff commented, "We never run out of snacks". A second staff stated she feels there are enough snacks offered to the residents on the "am" shift and provided examples of snacks as: Oreos, Graham crackers with peanut butter, fruit cups and sometimes bananas, but was not aware if there are sufficient snacks on the "pm" shift, of if they have ever run out. A third staff confirmed snacks are offered after lunch, and staff will serve snacks after lunch and during Bingo also, residents like snacks and are "always wanting food". *cont on 9099C-3.. 9099C-3..A fourth staff stated snacks are offered, at 4:00 pm, during activities, and around 7:00-7:30 pm, after dinner. This staff indicated that after dinner snacks consist of cookies, crackers, sandwiches, PB&J and ham and cheese, and bananas, and asserted "They need better quality snacks and more sandwiches and fruits" and also "more choices with beverages", including sugar free drinks , such as lemonade." This staff explained that a snack cart is left by the kitchen after dinner and by 7-7:30 pm, there is "nothing left" on it. This staff commented that some residents are "always asking for snacks", especially around 8:00 pm- 9:00 pm, stating "sometimes they don't have enough snacks, staff want to see consistent snacks, and staff should have access to the kitchen". LPA observed morning snack just served on December 4, 2025 (10:20 am) and (2) two residents eating a fruit cup (cut up pears) in one dining room. While walking to the other dining room, LPA observed a resident sitting in the common area in the hallway eating a fruit cup. LPA spoke with Activity Director who confirmed snacks are served during morning and afternoon activities at 2:00 pm, pointing to a tray of covered fruit cups near the punch container. This director confirmed she will offer snack to residents in the dining room and also to those sitting in the common areas/hallways. On December 22, 2025 (3:45 pm), LPA observed a partial plate of cookies in each dining room that was served for afternoon snack. A Med-Tech confirmed residents were served peanut butter and jelly sandwiches for morning snack today and that there are a few specific residents who will let staff know when they want a snack in the evening. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid- there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099C-4.. 9099C-4.. Allegation: Staff cannot communicate with residents due to language barrier. The allegation states staff cannot communicate with residents because staff cannot speak English, and staff will have to speak on a walkie-talkie and have it translated. The administrator stated on October 15, 2025 that there are typically (4) staff on a shift, and staff know enough English to communicate with the residents. (4) caregiver staff were interviewed. Both "am" staff indicated that there are no issues with staff not being able to communicate with residents, and stated "on the "am', we have good walkie-talkie etiquette". One "pm" staff interviewed stated "everyone knows how to speak in English" and there is no translation needed. A second "pm" staff stated some staff speak Spanish at the facility and do use a walkie-talkie to interpret for each other, and there were (2) staff who previously worked at the community who "could not speak English very well", but there are currently no staff who need other staff to assist. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid- there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit inter view. Copy of report provided.