Complaint·June 6, 2025

4 Out of 5 residents (R2-R5) interviewed stated they have not seen staff slapping/hitting residents or treating them in a rough manner. LPA Dolores interviewed staff S1. S1 stated an incident with two staff members (S2, S3) and R1 on 06/16/2023 or 06/17/2023. Based on S1's internal investigation, the staff members denied the allegation of slapping the resident or handling the resident in a rough manner. The staff did admit to assisting the resident with transferring the resident from their wheelchair to the bathroom. S1 stated prior to the incident, there had not been any concerns. S1 did stated R1 could not confirm the cause of the bruise on R1's arm. LPA Dolores interview witness W1. W1 stated he/she asked R1 about staff slapping R1. R1 was confused and could not answer the question. W1 reported seeing three (3) bruises on R1. W1 stated he/she believed that the bruises may have come from an assistive device that is installed in R1's bathroom. W1 stated R1 has a private caregiver, whom is not associated/employed with the facility, and observed the bruise on R1 on 06/17/2023. W1 stated in terms of R1’s definition of rough, he/she couldn’t get that information from R1. On May 28, 2025, LPA Monter interviewed residents R6-R13. All residents interviewed stated they have not seen staff slapping/hitting residents or treating them in a rough manner. LPA Monter interviewed staff S4-S9. All staff interviewed stated they have not seen staff hitting or slapping resident in care. 5 Out of 6 staff interviewed (S4-S7, S9) they have not seen staff handle residents in a rough manner. 1 Out of 6 staff (S8) stated he/she remembers of an event where two staff members were rough when providing care but could not remember where or when this occurred. On June 4 & 5, LPA Manuel Monter interviewed staff S2 and S3. Both staff interviewed stated they did not hit/slap residents in care. Both staff interviewed stated they did not treat residents in a rough manner. Both staff interviewed stated they haven’t seen staff hit/slap residents in care or staff treating residents in a rough manner. On June 6, 2025, LPA Monter interviewed staff S10. S10 stated he/she hasn't seen or heard about staff slapping/hitting residents or treating them in a rough manner. Page 2 Out of 3. Based on a review of Local Law enforcement report, on June 17, 2023, local law enforcement was informed about the alleged physical abuse of R1. The report indicates staff S2 and S3 as the two staff member in question who were alleged of doing physical abuse. Based on a review of R1’s Progress notes, dated June 21, 2023, states R1 informed staff that on June 16, 2023 two care givers were rough with him/her. R1 described the staff as Ethiopians, tall slender and could possibly be brothers/sisters. R1 stated when he/she was being transferred, one of the care givers hit him/her on his/her left arm and caused a bruise and a small skin tear. Based on a review of Accent Care Hospice Provider note, dated June 17, 2023, R1 noted pain to left elbow and skin tear to elbow. R1 stated he/she doesn’t remember exactly what happened but noted small drops of blood on floor to the left of toilet. Appears to have bumped his/her arm on the raised toilet seat handle. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. This report was reviewed with ADM Ida Gemignani-stearns and a copy of the report was provided. Page 3 Out of 3. END OF REPORT.