complaint·October 7, 2025

Staff that were interviewed were present in the memory care on 12/17/2024 during the AM shift. While providing assistance to another resident, S1 saw R1 on the ground in the adjoining living room. S1 got additional assistance from S2 who was also assisting with the other resident. S2 asked resident R1 what happened. According to S2, R1 said, “R2 pushed me,” and pointed to R2. Both staff were the only direct care staff in the area at the time and acknowledged R2 was by R1 in the living room. There is no video surveillance inside the facility. R1 was assessed by facility staff. Emergency services were called and transported R1 to the hospital for evaluation. For the records that were reviewed, both R1 and R2 have neuro cognitive disorders. R1 was noted as independent with mobility and transferring. R2 is noted as not having any inappropriate or aggressive behavior. While R1 sustained an injury while in care, there is no evidence that either R2 had inappropriate or aggressive behavior, and that additional supervision was needed to prevent a resident-on-resident altercation. There is no corroborating evidence that a lack of supervision resulted in R1 being pushed by R2 resulting in injury. Based on interviews, observations and records review, the department has determined 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, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 2 of 2