complaint·December 19, 2025

Allegation: Staff did not provide adequate supervision resulting in an altercation between residents. It was alleged that on 09/10/25 R1 got slapped by R2 and staff did not provide adequate supervision. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that during the morning and afternoon shifts (from 7am – 3:00pm) the facility has six (6) to seven (7) staff members, including two (2) MedTechs. LPA was also informed that the staff is always available to redirect residents in case an altercation or any type of disagreement between the residents occurs. Interview with three (3) staff members confirmed the statement provided by the Administrator. All staff interviewed informed the LPA that no serious injury was reported during R1's and R2’s incident. This was the first time that R1 and R2 had an altercation and no previous incidents between the two had ever happened in the past. According to the R1's Physician's Report (dated on 07/13/23) and R2's (dated on 04/29/25) both residents have a history of depression. Administrator also informed LPA that R1 has a history of confusion, however, both residents have never had a history of aggression. Interviews with fourteen (14) out of seventeen (17) residents revealed that residents may occasionally argue and or disagree, however, the staff is well trained to prevent altercation and an immediate staff intervention/redirection is being provided. According to a police report (dated on 09/10/25), R2 instigated the altercation when R2 interrupted a conversation between R1 and another resident, which turned into an argument, and then R2 slapped R1 one time on the right side of the face. The two were eventually separated by the staff and no further medical attention was required or requested by both residents. Although there was an altercation between R1 and R2, that lead to R2 striking R1, there wasn't enough evidence to prove that staff did not prevent resident from hitting another resident in care, as there was staff supervision present to intervene and redirect both residents. Moreover, licensee did submit an Incident Report (IR) to the Licensing agency regarding the incident. Therefore, based on the information obtained the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and d elivered.