Complaint Investigation Report

Regarding Allegation #1 : Staff do not prevent resident from hitting another resident.

This complaint claimed that staff did not stop staff member from hitting R1 on the head. LPA Calderon and S1 toured the facility. LPA Calderon did not notice any negative interactions between staff and residents. LPA Calderon noted the injury to R1 head appears to be more consistent with R1 contacting the floor vs being struck with a cell phone. Records indicate the following: Physician report and Needs and Service Plan indicate that R1 has cognitive issues and is non-verbal. The incident report indicates that R1 was found on the floor with a bloody forehead. R1 indicates to the police that a female caregiver struck R1 in the head with a cell phone and then pushed R1 while in the wheelchair. The interviews indicate the following: S1 indicates that on 08/10/2025 R1 was found on the floor with a bloody forehead by staff. S1 indicates that 911 was called and R1 was taken to the hospital for treatment. S1 indicates that R1 claimed that a female staff member struck R1 in the head with a cell phone and then pushed R1 while in the wheelchair. S1 indicates that R1 changed R1 story and claimed that a male staff struck him in the head. S2 indicates that R1 was watching TV and lost R1 balance and fell to the ground. S2 indicates that S2 would never strike a resident in care. S1-S3 deny the allegation ever happened. R1 is non-verbal and can only write R1 answers to questions. R1 indicates that an unknown female staff struck R1 in the head causing injury. R1 indicates that R1 wrote down the same version to the police. 2 out 3 residents indicate that no staff has ever abused any resident in care. 2 out of 3 residents indicate that they have not seen any staff member hit or abuse R1.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff do not prevent resident from hitting another resident” is found to be UNSUBSTANTIATED.