Complaint·December 17, 2025

[Continuation from LIC 9099] A review of R1’s records revealed they were admitted to the facility on February 3, 2025. Prior to admission, R1 had undergone two hip and knee replacements and was diagnosed with Mild Intellectual Disorder (MID), macular degeneration, depression, hypertension, and anxiety. R1 was non-ambulatory, considered a fall risk, but was able to leave the facility unassisted. A review of R2’s records showed they were admitted on February 29, 2024, following a stay at a Skilled Nursing Facility (SNF) due to a hip fracture. R2 was non-ambulatory and diagnosed with MID, atrial fibrillation (A-fib), hypertension, chronic obstructive pulmonary disease (COPD), depression, anxiety, Hyperlipidemia, arthritis, alcohol use disorder (ETOH), and alcoholic hepatitis. Records also indicated R2 was easily agitated but generally kept to themselves. Interviews with S1 and the facility’s Executive Director (ED) described R2 as quiet and non-problematic, and both expressed surprise at the allegation. They confirmed that no further incidents had occurred. The ED, who was informed of the incident by R1, stated that R1 and R2 had crossed paths at the facility and were in each other’s way when R2 swatted R1 on the bottom. Additionally, Staff 3 (S3) reported that no staff witnessed the incident and that all residents were gathered in the dining hall for dinner at the time. A review of outside source records corroborated that R1 preferred the facility to handle the situation, and did not wish to press charges. An additional interview conducted with R1 corroborated and they confirmed no other occurrences have happened at the facility . The incident was self reported to the Department on February 8, 2025, the day of the incident. Based on interviews and records reviews the allegation was determined to be Unsubstantiated. An Unsubstantiated finding means, although the allegation may be valid there was not a preponderance of evidence to prove the violation had occurred. An exit interview was conducted with CBD Totorica, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided. Signature below confirms receipt of the reports.