complaint·April 16, 2026

(continue from LIC9099) The Department’s investigation included a facility tour, interviews with R1, staff, eight (8) resident witnesses, and outside sources, as well as a review of records including the SOC 341 report, internal incident report, LIC 624, progress notes, and nursing assessments. On 02/19/2026, LPA interviewed R1 at the facility. R1 was observed to be alert and able to engage in conversation. R1 reported that several days prior, after 10:00 p.m., while watching television in the lounge, a female staff member became upset, took the remote control from R1, and struck R1 in the face. R1 stated that several staff members were talking loudly, making it difficult to hear the television, and R1 increased the volume. R1 reported that the staff member yelled at R1 to be quiet and go to sleep, refused to return the remote, and then slapped R1. R1 stated R1 left the lounge feeling upset and reported the incident the following morning. R1 reported R1 did not tell other residents due to embarrassment and did not inform family to avoid causing problems with staff. R1 stated this was the only time a staff member had hit R1 and reported no additional concerns. R1 was unable to identify the staff member involved, provide a specific date, or identify any witnesses present. R1 stated R1 currently feels safe in the facility. Staff interviews were conducted with supervisory staff and staff working during the relevant shifts. Staff reported that R1 initially stated that a female staff member took the remote control and slapped R1; however, during follow-up, R1 declined or was unable to provide additional details. Staff reported that R1 was assessed following the allegation, and no visible injuries, including redness, bruising, or swelling, were observed. R1 was noted to be at baseline and not in distress. Staff reported that an internal investigation was conducted, including interviews with staff on duty, and all staff denied the allegation and reported they did not witness any incident or inappropriate interaction between staff and residents. Staff reported that R1 was unable to identify any staff on duty at the time of the alleged incident. Staff further reported that there have been no prior similar incidents or concerns regarding staff performance. (Continue on LIC9099C) (continue from LIC9099C) Eight (8) residents were interviewed regarding the alleged incident. None reported being present during the alleged incident, observing any staff strike or mistreat R1, hearing any argument or disturbance, or receiving any disclosure from R1 regarding being struck. None of the residents reported observing injuries or distress in R1. No resident provided information to corroborate the allegation. A review of records, including the SOC 341 abuse report, LIC 624 incident report, progress notes dated 02/13/2026 through 02/17/2026, and nursing assessments, indicated no visible injuries such as redness, bruising, or swelling, and no documented distress or behavioral changes. Documentation reflected that the facility reported the incident in a timely manner and completed required follow-up assessments as required per Title 22 regulations. Although R1 provided a consistent statement that R1 was struck by a staff member and appeared credible during the interview, R1 was unable to identify the staff member involved, provide a specific date, or identify any witnesses. No staff or residents reported witnessing or hearing the alleged incident, and no physical evidence or documentation supported the occurrence of injury. Based on the investigation, including interviews, observations, and record review, there is insufficient evidence to substantiate the allegation. Therefore, the allegation that staff struck R1 is deemed unsubstantiated. An exit interview was conducted with Administrator Kathy Gabriel. A copy of this report and the Licensee Appeal Rights (LIC 9058 03/22) were provided at the time of the visit.