complaint·April 25, 2025

S1 states he/she and a Private Caregiver (referred to as PC) were in the dining area. S1 was serving lunch to a resident. S1 states he/she observed R1 touch R2 on the arm and stomach. S1 states he/she then heard R2 tell R1 to not touch him/her. S1 stated when he/she saw/heard this, he/she walked towards both residents. S1 stated while he/she was walking towards R1 and R2, that is when R1 touched R2 again, and R2 pushed R1 causing R1 to fall to the ground. S1 stated this all happened in less than 10 seconds. During interviews both individuals were busy with clients when then heard R1 and R2 arguing. Staff S11 stated he/she had just clocked in the day of the incident. S11 stated he/she was in the staff lounge area walking towards the dining room. S11 stated as he/she entered the dining room, S11 stated he/she saw R2 make contact with his/her arm toward R1, and saw R1 fall. S11 described the hand motion as a swiping motion, in R1's direction. S11 stated he/she saw S1 walking in the direction of both R1 and R2. S11 stated S1 was in the middle of the dining area, when the incident occurred. Residents were in the dining area at approximately 2PM, S1 heard R1 and R2 talking and heard R2 state “Don’t touch me” to R1. According to staff, they heard R1 and R2 briefly exchange conversation. LPAs interviewed PC on 4/1/2025 and states he/she was in the middle of the dining room on 11/15/2024. PC states that he/she was taking care of his/her resident when he/she observed R1 push R2. PC states that S1 went over to assist R1 when R2 pushed R1 down to the ground. LPAs interviewed 6 residents, R1-R5. 3 Out of 6 residents stated they did not observe the incident between R1 and R2. 3 Out 6 residents did not respond to questions due to neurocognitive disorder. LPAs reviewed physician’s reports for R1 and R2. R1’s physician’s report dated 12/3/2024 with a primary diagnosis of neurocognitive disorder , associated with “confusion, and sundowning behavior.” On the other hand, R2’s physician’s report dated 3/15/2023 with a primary diagnosis of neurocognitive disorder, associated with a mental condition of ‘confusion, inappropriate behavior and aggressive behavior.’ Page 2 of 3 ’LPAs reviewed R1 and R2’s appraisal needs and care plans dated 12/11/2023 and 12/27/2023. R1 and R2 have similar behaviors of aggression due to his/her neurocognitive disorder wherein both residents require supervision by staff. LPAs obtained and reviewed staff daily notes for R1 from 11/19/2024-12/11/2024. R2 had a previous incident documented on 8/16/2024, where R2 had aggressive behavior involving foul language and being physically too close to another resident. The Department has completed the investigation of the above allegation. Based on interviews conducted and record reviews, the Department has found that the above allegation is UNSUBSTANTIATED. Although the allegation that resident R1 pushed R2 is true, there is not a preponderance of evidence to prove that the allegations did or did not occur. An exit interview was conducted with Activities Director Michelle White and a copy of the report was provided.