complaint·March 3, 2026

(Continuation from LIC9099) Interview with S2 reported that S2 was standing near the entryway of the main room when S2 overheard a loud slapping noise. S2 reportedly rushed towards the noise and observed R2 with their hand raised and began hitting R1 with an open hand. S2 reported observing S1 separating the resident and S2 assisted with redirecting R1 away from R2. After the residents were separated, staff reported that S2 contacted emergency personnel as R1’s left side of the forehead had light bleeding. Staff report that R1 had prior stitching due to an unrelated incident. As a result of the physical altercation, a stitch on R1’s forehead was removed. Staff interviews reported that S2 contacted emergency personnel. Upon emergency personnel’s arrival, R1 was transported to the hospital due to the stitch being removed from R1’s head. Interviews with staff and Witness #1 (W1) reported that R2 was not observed to have sustained any injuries. Staff interviews reported that R2 does not have a history being physically or verbally aggressive towards residents and does not require constant care and supervision. LPA attempted to interview R1 and R2 but due to cognitive abilities, the interview attempts were unsuccessful. A review of R2’s care plan details that R2 requires checks at more frequent interval and may exhibit physically or verbally aggressive behaviors. A review of R1’s care plan detailed that R1 requires checks a regular intervals and has a history of aggressive behaviors in prior facilities. Records review conducted for R1 and R2 does not report either residents requiring constant care and supervision. Interview with Administrator explained that regular checks are conducted every two hours and frequent checks are conducted every hour. LPA was informed that the facility does not maintain surveillance cameras in that location of the building. Due to insufficient evidence, the allegation of staff did not prevent one resident from hitting another resident is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the allegation did or did not occur. An exit interview was conducted, and a copy of this report was provided to Administrator Kylee Carter.