complaint·April 24, 2026

A review of the Department’s incident report log shows there were no incident reports for R2 prior to this alleged incident. A review of physician’s reports and needs and service plan for R1 states resident is level two (02) with Mild Cognitive Impairment, is able to translocate and able to perform activities of daily living with some assistance. R1 is unable to leave the facility unassisted. A review of physician’s reports and needs and service plan for R2 states resident is a level one (01) with Mild Cognitive Impairment, disorientation with days of the week, however, all other behavioral expressions state that R2 has impulse control, does not hallucinate, elope or wander. R2 is also ambulatory and able to leave the facility unassisted. A review of the staff schedule for December 19, 2025 shows there were at least four (04) caregivers and two (02) MedTechs per shift. During interviews, all staff stated they did not witness the incident but were in the area, approximately twenty (20) feet from the incident, and immediately went to R1’s aid and called for emergency services. Staff #1 (S1) and Staff #2 (S2) stated when they asked the residents, R1 explained they were touched on the shoulder and lost balance when trying to look back. Staff added all residents are checked on at minimum every two (02) hours. During interviews with residents, R1 stated they were feeling dizzy that day and R2 was always too excited to get their attention and tapped R1 on the shoulder. R1 explained that the fall was a result of trying to look back at the same time. R1 added R2 would wait by the doorway to get an opportunity to speak with R1 and found it strange. R1 explained the tap may have been too hard and could have been gentler in trying to get their attention. R1 added R2 has a relationship partner now and is no longer a bother. R1 feels there is adequate supervision in the facility. R2 stated they have never physically assaulted anyone. All other residents stated they have never experienced an altercation with R2 or witnessed R2 having any physical alterations with other residents. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not intervene to prevent inappropriate physical contact between residents. It was alleged that R2 kissed R1 on the forehead on December 17, 2025, got super close, and made R1 uncomfortable. To investigate the allegation, on March 18, 2026, LPA requested documents at around 9:30 a.m., interviewed three (03) staff from 10:30a.m. – 12:00p.m., seven (07) residents from 12:00p.m. to 2:30p.m. On April 24, 2026, LPA interviewed an additional three (03) residents at around 10:30a.m. (CONT on LIC9099-C) A review of the Department’s incident report log shows there were no incident reports for R2 prior to this alleged incident. A review of physician’s reports and needs and service plan for R2 shows resident is a level one (01) with Mild Cognitive Impairment, disorientation with days of the week, however, all other behavioral expressions state that R2 has impulse control, does not hallucinate, elope or wander. During interviews, all staff stated they are not aware of R2 kissing R1 on the forehead or aware of R2 making R1 feel uncomfortable. During interviews with residents, R1 stated R2 kissed them on the forehead and made them uncomfortable. R1 added they feel safe in the community around R2 as they are no longer pursuing a relationship. R2 stated they do not recall kissing R1 on the forehead. All other residents stated they feel safe in the community and have not witnessed any inappropriate contact between R2 and R1. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.