Complaint Investigation Report

Allegation: Staff do not provide a safe environment for residents resulting in injury. The complaint alleges that resident (R1) was injured by another resident (R2) on at least two separate occasions. According to information obtained, approximately two weeks ago R1's had a hand print on their back and last week R1 had "deep scratches" under their eyes, nose, ears, and around the throat and neck. Resident (R1) was interviewed and confirmed the incident occurred in the bathroom. Resident (R1) stated R2 got mad and scratched their face. An interview was attempted with resident (R2), but the resident is unable to communicate. Resident (R3) had limited knowledge of the incident. A total of five staff were interviewed. Staff (S1) was the staff working the night shift the day of the incident. The incident took place on Friday, May 8, 2026 at approximately 2:15 AM. Staff (S1) stated that R1 got up to use the bathroom in the middle of the night and S1 went to the bathroom to assist the resident. While the resident was sitting on the toilet, resident (R2) entered the bathroom to also use the bathroom. R2 did not see R1 was sitting on the toilet and reacted aggressively. Resident (R2) scratched R1's face and ear. Staff (S1) was present in the bathroom during the incident and immediately intervened by separating the residents and redirecting R2 back to their room. Staff (S1) did a body check and observed scratches on R1's face. Both residents returned to their room and fell asleep. Staff interviews revealed that both residents have history of some aggression, but this is the first time that they are aggressive towards each other. The residents are roommates in the same room and no other physical altercations have occurred in the past. Staff stated the hand print on the back was observed after R1 returned from school. Record review revealed that both residents have history of aggressive behaviors characteristic of level 5 facilities that serve developmentally/intellectually disabled adults. Based on observation, resident (R1's) face scratches appear to have been minor and are healing well. No scratches were noted in R1's neck and throat. There is insufficient evidence to corroborate the allegation.

Allegation: Staff do not obtain medical care for resident. The complaint alleges that on May 8, 2026, resident (R1) was scratched in their face, ears, nose, neck and throat by resident (R2). It is alleged that the scratch near the eye appeared to untreated because it appeared deep and there was no band aid covering the scratches. Staff (S1) stated that immediately following the incident R1 was provided 1st Aid treatment. Staff cleaned the scratches and applied hydrogen peroxide, antibiotic cream, and a band aid. All staff denied the allegation. They stated that 1st Aid treatment is always performed. Interviews revealed that when staff (S1's) shift ended at 6:00 AM, the morning shift staff was informed of the incident and observed a band aid on R1's scratches. The scratches were cleaned again prior to R1 being sent to school. Morning staff also applied a band aid, but stated that R1 did not want a band aid on their face. Resident (R1) stated S1 put cream on their face and a band aid, but they took off the band aid. Therefore, the allegation cannot be supported.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated .

Exit interview was conducted with Administrator Lourdes Almeida. A copy of the report was provided.