Complaint Investigation Report

Multiple relevant parties reported residents sustaining unexplained injuries. One relevant party reported that R1 is sustaining unexplained bruises and believes bruises have been sustained by rough handling from staff. Another relevant party reported that resident (R2) sustained circular bracelet marks around their wrist, and R2 expressed pain from the marks. Another relevant party reported that facility has a staff member who hits the residents in care and facility is knowingly covering up the incidents of physical abuse.

Interview with local long-term care ombudsman (LTCO) indicated that the circular marks around R2’s wrists were old injuries that do not match what was reported by the facility. Interview with Alta California Regional Center (ACRC) representative confirmed LTCO’s statement that R2’s injuries sustained on their wrists were older injuries and did not match what was reported by facility. Interview with regional center representative indicated that injuries were documented on a shared information report and should have been reported as a Special Incident Report (SIR) to regional center and CCLD. LPA Hood observed R2’s injuries during the investigation and received shared information report on 8/01/2024 indicating that injury was observed on 7/25/2024.

LPA Hood observed a shared information report on file for R1 dated 12/14/2023, indicating that R1 was observed to have sustained a bruise on top of their right foot with no known incident to account for injury. LPA Hood observed a shared information report on file for R1 dated 2/16/2024 indicating that R1 twisted their ankle while exiting the facility van. Report indicates that PRN was given for pain and R1 was at baseline. LPA Hood observed a shared information report on file for R1 dated 4/23/2024 indicating that R1 sustained an inch long bruise on their forearm with no unusual incident observed regarding R1 sustaining injury. LPA Hood observed a shared information report on file for R1 dated 5/7/2024 indicating R1 sustained a bruise on stomach and right arm. Report does not indicate any incidents associated to R1 sustaining injury.

Interview with staff members S3 and S5 indicated that they witnessed staff member (S1) slap resident (R3) on the hand. Interview with S3 and S5 indicated that the incident was reported to Acting Administrator (S8) and staff were told by S8 not to lie about other staff. S3 and S5 stated that R3 reported that S1 hit them to S8, but statement from R3 was ignored by S8.