Allegation: Staff caused injury to a resident in care.

It is being reported that R1 was observed with a bruise on their right forearm and stated that staff were abusing him. On 6/3/26, LPA Felisa Shirley reviewed Special Incident Reports for the months of March, April and May 2026 and did not observe any reports of injury to residents by staff members. During review of Special Incident Reports on 6/3/26, LPA Shirley observed an incident dated, 5/19/26 stating R1 had some discoloration to his right forearm. On 6/3/26, LPA Shirley reviewed the 24-Hour Communication Log dated 5/18/26, stating R1 was upset because he was being transferred to another room. The review of 24-Hour Communication Log also revealed that R1 had bruises on 5/19/26 and the Med-Tech was notified. On 6/3/26, LPA Shirley observed a large dark burgundy bruise on R1’s right forearm. During interviews on 6/3/26, R1 stated 3 to 4 staff workers were pulling his arms while dragging him on the floor preventing him from going home. Per interview with S1, R1 was transported to Long Beach Memorial, non-emergency transport on 5/19/26, and R1 returned to the facility the same day and R1 did not have discharge paperwork. LPA Shirley observed a yellow “Fall Risk” wristband on R1’s wrist. Per review of R1’s Physician Report dated 10/2/25, R1 was not noted as being a fall risk. Per review of R1’s Service Plan dated 3/2/26, R1 was not assessed as being a fall risk. Per interview with S1, R1 will be assessed for frequent falls. Per interview with S2 on 6/3/26, R1 became aggressive on 5/18/26 after learning that he was being transferred to another room and unit. S2 stated R1 threw himself onto the floor, kept hitting his arms on the railings and refused to get up. S4 and S5 stated during interviews on 6/3/26, R1 was very aggressive, swinging his arms and hitting both arms on the floor and moving his body refusing to get up from the floor. Per interview with S2 on 6/3/26, S2 placed his hands under R1’s armpits and shoulders to lift R1 up into the wheelchair to continue to transfer R1 to his new unit and room. Per interview with S1 on 6/3/26, R1 did not have the bruise on his arm on 5/18/26, the day before the room transfer.

It was also reported that R2 was working for free labor, as the facility is short staffed and needs the help. It was reported that the reporting party thought that R2 was a staff member until it was realized that he was a resident. Per interview with R2 on 6/3/26, no one has ever ask him to perform duties for the facility nor the residents that reside inside the facility. R2 stated that he likes to help out and be appreciated. He see’s the duties that needs to be done and he does it. When someone ask, who swept that floor, I would say that I did it and it’s no problem.

Con'd on 9099-C

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff caused injury to a resident in care,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Executive Director, Esperanza Naaktgeboren.