Complaint Investigation Report

On October 15, 2025, the Department received an IR for resident R2. The IR stated on October 14, 2025, at approximately 6:50-7:00pm, R1 was exhibiting behaviors (yelling and making noise in his/her bedroom.) R2 exited his/her bedroom and approached R1’s bedroom, which was locked with R1 and a staff member inside. Upon finding R1’s room locked, R2 began banging on it and kicking the door, demanding the door be opened. Two staff members intervened, attempting to redirect and R2 stuck staff members. Staff contacted local law enforcement and R2 was taken to the hospital.

On November 4, 2025, LPA Manuel Monter interviewed residents R4 and R5. Resident R4 stated he/she doesn’t remember what occurred on October 14, 2025 and was unable to provide any relevant information regarding the allegation. LPA attempted to interviewed resident R5, but R5 did not provide any responses to questions posed and did not provide any relevant information regarding the allegation.

LPA Manuel Monter interviewed staff S1-S6. 5 Out of 6 Staff (S1-S5) stated they were working on October 14, 2025 when R1 fell. S1 stated he/she was attending to resident R3 when R1 had fallen.

S3 stated around 3:40-3:50pm, he/she was transferring R1 from his/her bed to the family chair, R1 then slid and was being combative (hitting in a slapping like motion and trying to pull hair). S3 stated as R1 was falling, he/she managed to hold R1 so he/she didn’t fall. S3 stated he/she didn’t see R1 hit anything. S3 stated he/she called for assistance. S3 stated S2 tried to help but wasn’t able to assist, due to R1’s combativeness. S3 stated that staff S4 was able to get R1 up. S3 stated there was no injury noted on R1. S3 stated the following day, after the fall, they did notice a noticeable mark on R1’s face in the morning, which became more noticeable in the afternoon. S3 stated the same day, around 7:00pm, R2 did have a behavior. S3 stated he/she was not with R1 at the time. S3 stated R2 was upset with resident R3. S3 stated he/she was doing laundry at the time.

S2 stated around 3:30pm, he/she was preparing a meal for R1, when staff S3 called for help. S2 stated he/she and S4 went to go assist. S2 stated staff S3 couldn’t get R1 up because R1 was pulling and pushing S3. S2 stated he/she attempted to help R1, but R1 was being combative. S2 stated he/she asked staff S4 to help. S2 stated the same day, around 7:00pm, R2 was having a behavior, as he/she was in R1’s room. S2 stated as staff assisted R3 to the bathroom, R2 then attacked resident R3. S2 stated R2 was throwing things and trying to get “revenge” because R2 thought, R3 had yelled at him/her. Page 2 Out of 4.