Incident investigation·March 24, 2026

Licensing Program Analyst (LPA) Christina Valerio and LPA Reza Jamaly arrived unannounced to conduct a case management visit to follow up on an incident report. LPAs met with Administrator Rosalie Sullivan, and explained the purpose of the visit. On March 14, 2026, The Regional Office received an incident report and SOC 341 from the facility. The incident involved Resident 1 (R1) and Resident 2 (R2). R1 was observed by staff touching R2 and became aggressive towards staff when staff intervened. Both residents were sent out for further evaluation, responsible parties were contacted, law enforcement was contacted, and long term care ombudsman was contacted. LPAs obtained and reviewed facility documentation, such as, staff progress observation notes from the day of the incident, staff statements, and discharge plan for R1. Based on the review of documents collected and interviews conducted, no deficiencies are being cited. An exit interview was held, and a copy of this report was provided.