Complaint Investigation Report

On 11/25/25, LPA toured inside and outside of the facility and observed it to be clean. On 01/09/2026, LPA toured the facility and observed it to be clean. Two out of two staff interviews indicated that the facility is cleaned daily. Witness #2 interview indicated during past visits, the facility was clean.

Regarding the allegation, “Staff are not keeping facility and grounds clean,” based on observation and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

Allegation: Staff are physically abusing residents in care.

Regarding the allegation, “Staff are physically abusing residents in care,” it is being alleged that staff are heard yelling, followed by slapping noises and then screaming by the resident. Record review of C1’s physician’s report (06/23/25) revealed C1 screams. Review of Behavioral Plan (09/15/24) revealed staff will involve C1 in regular activities where C1 can expend energy as a solution to agitation/screaming. Review of C2’s Physician’s Report (08/30/25) and IPP (03/14/25) revealed C2 bangs head on the wall and hitting self. C2 is to have consistent one-to-one engagement. C4’s Physician Report (06/23/25) revealed C4 screams. C4’s IPP revealed C4 has self-injurious behaviors. The 2025 – 2026 behavioral ISP revealed C4’s short-term goal is to decrease screams to four times per month and reduce self-injurious behaviors down to five incidents per month. Record review of November and December observation reports revealed C1 and C4 had quarter size bruise and one inch cut on their bodies. S2 indicated three out of four clients yell. S4 indicated two clients scream nonstop in the evenings of October and November. S4 tries to calm C1 and C3 but it is difficult. S4 indicated C1 creates loud noises by tapping on the chair, floor, and wall. S4 raises tone but it does not work. Witness #1 - #2 denied the allegation. Witness #4 indicated that body check documents of bruises and scratches are sent to the facility. On 11/25/25, LPA did not observe any signs of physical abuse. LPA heard one client making noise in the client’s bedroom. On 01/09/2026, LPA observed one out of three clients (C1, C2, and C4) making noise in the living room chair. LPA observed video of two of four clients screaming and hitting wheelchair/chair.

Regarding the allegation, “Staff are physically abusing residents in care,” based on record reviews, observations, and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Continue to LIC9099-C.