Complaint Investigation Report

Facility staff S2 stated that R1’s nurse has informed facility staff not to hold the resident by their arms as the resident skin is soft, and they easily bruise. Interview with 2 out of 4 residents in care expressed no concerns with ever observing facility staff harm other residents in care or harm them. LPA attempted to interview resident (R1) but was unable as the resident has very limited English-speaking capabilities. LPA attempted to contact the Reporting Party (RP) several times but never received a call back. LPA observed resident (R1) in the facility, they appeared calm and responsive to facility staff. Facility staff (S1) showed LPA R1’s arms which appeared normal, without any visible signs of injury. There is not enough evidence to corroborate this allegation, therefore the allegation is unsubstantiated.

Allegation: Staff handled resident in a rough manner.

It was alleged that staff handled a resident in a rough manner. This investigation consisted of interviews with facility staff, residents and facility observation. On 1/14/2026 LPA Hughes conducted a visit to the facility and spoke with facility staff (S1) who stated that resident (R1) has calmed down while residing in the facility, stating that R1 medications have changed and the facility no longer has daily challenges with the resident. S1 denied allegations of ever observing a facility staff handle a resident roughly. Interview with facility staff (S2) stated that they have never handled any residents roughly, stating that all residents are treated and handled with care. Facility staff (S2) stated that in the past resident (R1) would inflict physical assault on staff, but their temperament has become more responsive to facility staff. Facility staff (S2) stated that R1’s nurse has informed staff to handle the resident from different angles to prevent bruising. Interview with 2 out of 4 residents did not express any concerns about ever observing a facility staff handle a resident in a rough manner or ever being handled roughly themselves. LPA attempted to interview resident (R1) but was unable as they have limited English speaking capabilities. LPA attempted to speak with the Reporting Party several times but never received a return call. During the visit on 1/14/2026 LPA observed facility staff preparing dinner, and assisting residents to the dining area. Due to insufficient evidence, this allegation is unsubstantiated.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.