complaint·January 11, 2024

It was alleged that due to staff’s neglect and lack of supervision, residents got into a physical altercation resulting in severe injuries. Facility interviews revealed facility staff reported seeing Resident 1 (R1) around the dining room and back patio area on the day of the incident. Staff also reported having checked on Resident 2 (R2) in their bedroom on an hourly basis on the same day. Neither resident had a history of aggression or assault. Therefore, no warnings were in place that would warrant staff taking measures to prevent such an occurrence. On the day of the incident, which as 01/24/2022, at approximately 5:30pm, a physical altercation took place, between R1 and R2, resulting in R1 suffering injuries to their face. After the residents were separated by facility staff, R1 was transported to a local hospital for evaluation and treatment. As a result of the interviews conducted and records reviewed, it was determined that R1 erroneously entered R2’s room and a physical altercation ensued. According to resident interviews, R1 attempted to punch R2, and R2 defended themselves by punching R1. According to all parties interviewed, staff were alerted to the altercation and responded immediately to separate the residents. Insufficient evidence exists to prove that this was as a result of facility staff’s neglect and/or lack of supervision as such the allegation is Unsubstantiated. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No citations are being issued as a result of this compliant investigation. An exit interview was conducted and a copy of this report was provided along with a copies of the LIC9099C, and LIC811 (confidential names list).