complaint·October 10, 2024

RW1 stated that they untied sheet tied to the bed rails and called the staff into the room and asked why they were tied to the bed.” Staff 3 (S3) responded, “resident plays with their finesse.” RW1 told S3 that it was illegal to tie up and restrict residents and untied the remaining sheets from the bed. On 10/07/2024, LPA Jeffries conducted a phone interview with Reliable Witness 2 (a person with license or credentials indicating expertise training and/or experience) RW2 stated that, while visiting the facility on 10/04/2024, they interviewed Staff 1 (S1) who when asked about residents being tied to the bed by sheets, S1 stated, “they do that because (the resident) will dig in their fesses.” When S1 was asked by RW2, as a former Administrator at this facility, how could you let this happen? S1 stated “What’s the point? I just work here. It’s my aunt’s business. And they are going to do what they are going to do.” RW2 stated that S1 never disclosed staff which staff tied residents to their bed with sheets. On 10/10/2024 LPA Jeffries arrived at the facility and conducted interviews of Licensee/Administrator, Angelita Maravillas, who stated the R1 had stage 1 to 2 wounds on their buttocks, lower back, and ankles. Licensee/Administrator stated that she “knew it was wrong” but tied R1 down with the bed with sheet so R1 would not dig into their wounds on the buttocks and back. Administrator stated only she and S2 tied R1 down to the bed with bedsheet and no other staff participated in the restraint process with tying the R1 with a bed sheet to the bed rails. LPA Jeffries interviewed 4 of 4 residents. LPA noted that only 1 of 4 Residents were capable of a full cognitive conversation. At 9:02am on 10/10/2024, LPA Jeffries attempted to interview R1, when asked if they have ever been restrained by anyone in this facility, R1 replied, “I don’t know.” When asked if they had even been tied down in the bed at this facility R1 stated, “I don’t know.” At 9:13am on 10/10/2024 LPA Jeffries interviewed R2. R2 stated that they feel safe in the facility and has never been restrained and no personal rights issues have ever been violated in this facility by staff. At this time there is enough evidence by admission to the allegation of, “Staff inappropriately restrained resident in care.” And is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.