Allegation: “Staff handled a resident roughly, resulting in injuries”. It is alleged that on 04/06/2026, during the implementation of Crisis Prevention Intervention (CPI) approved holds on C1, staff members held C1 down in a manner that C1 was unable to breathe, causing scrapes to its left toes and right-hand knuckles. All (5) staff members who were interviewed and present during the incident denied the allegation. All staff stated they would never hit or abuse any of the clients in the facility. Interviewed staff stated that C1 acted aggressively on Friday, April 3, 2026, (not April 6, 2026) as a result of being denied what C1 wanted. C1 started screaming at the staff and kicking furniture. When C1 kicked the table, it caused the left toe injury and C1 refused first aid. C1 also tried to hit S1 and other staff and started throwing objects around that could have caused discoloration on C1’s right hand. Interviewed staff stated they made several attempts to verbally redirect C1, but it was unsuccessful. In response to C1's threatening behavior, and to prevent escalation, (3) staff members alternately used the CPI hold on C1 as a last resort. Staff indicated that they used the proper techniques based on their CPI training. C2 stated that the staff treat them well and have never hit them or handled them roughly. During the visit, LPA observed that C1 did not appear to be withdrawn or fearful. LPA also observed that C1's toe was bandaged, but there were no injuries to C1's head or right hand. Therefore, there is insufficient evidence to corroborate the allegation.

Allegation: “Staff spoke inappropriately to a resident”. It is alleged that staff members antagonized and teased C1 about the money. No other information provided. A total of (5) staff members were interviewed, and all denied the allegation. All staff interviewed stated they completed training on zero tolerance policy regarding abuse and neglect and would never speak inappropriately to clients. S1 stated that an incident occurred on Friday, April 3, 2026, where C1 became aggressive after their conservator denied C1’s request for more money. S1 informed C1 they cannot give them additional money, but staff did not tease C1. Staff stated that the situation escalated, resulting in a CPI hold, and mental evaluation and later hospitalization for a 5150 hold. LPA reviewed the incident report dated 04/05/2026 which supported these details. C2 denied the allegation and indicated that staff treat them with respect and have not spoken improperly to them. LPA did not observe disrespectful behavior from staff during the visit. Therefore, there is insufficient evidence to corroborate the allegation.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held and a copy of this report was provided to Hannah Ortega, Administrator in Training.