1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | [CONTINUED FROM LIC 9099, Page 1]
Staff Interviews revealed that Staff 1 (S1) reported that Resident 1 (R1) frequently displayed confusion and forgetfulness, often misplacing items and accusing staff of theft. S1 also noted that R1 would yell at caregivers during routine care, particularly when being repositioned in bed, and sometimes claimed she was being hurt despite staff using gentle techniques. Staff 2 (S2) described R1 as a challenging resident who often yelled during care and expressed dissatisfaction with assistance, especially during diaper changes. S2 stated that R1 was forgetful and had not witnessed any abuse at the facility.
Resident Interviews revealed R1 was able to state their name and location but had difficulty orienting to time. When asked about the alleged abuse, R1 could not recall the names of any staff members involved and stated that the incident occurred at a previous facility, not the current one. R1 repeated on at least three occasions that the abuse did not happen at the current facility. R1 was unable to identify any physical injuries or locations on their body where abuse may have occurred and changed the subject when prompted. R1 also made a threatening statement toward caregivers during the interview.
Outside Source Interviews revealed Outside sources (OS1, OS2, and OS3) consistently reported that R1 has a history of making unsubstantiated claims, including past allegations of abuse against family members that were investigated and found to be unfounded. OS1 and OS2 confirmed that law enforcement and APS visited the facility and found no evidence of abuse. OS1 noted that R1 denied any abuse during the law enforcement visit and expressed confidence in the facility’s reporting practices. OS2 stated that R1’s cognitive condition contributes to their behavior and expressed general satisfaction with the care provided. OS3 also confirmed that they had never observed any mistreatment of R1 and believed the staff were attentive.
Records Review revealed that in the Preplacement Appraisal (Dated 04/03/2025), R1’s diagnoses included vascular dementia and psychotic disturbance. Indicates R1 is non-ambulatory, forgetful, and requires full assistance with ADLs. This corroborates staff and outside source interviews.
Based on interviews, record reviews, and direct LPA observations, there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Caregiver tCarmelita Herreria, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. |