complaint·October 8, 2024

Facility staff pinched and slapped a resident's face: The allegation is that facility staff S1 tried to feed resident R1 but R1 refused to be fed, and S1 pinched and slapped R1's face. On 11/9/2023, LPA interviewed Administrator (ADM) Bradley Burgoyns. ADM stated the incident is under investigation. ADM stated the facility is unable to substantiate it. But the internal investigation finding report is not finalized yet. ADM stated staff S1 is under suspension by the facility protocol. ADM stated resident R1 was evaluated immediately after he/she received the incident report. ADM stated R1 was observed without injury and without sign of abuse. LPA interviewed Memory Care Unit Director (MCD). MCD stated resident R1 eats meals by himself/herself. MCD stated staff S2, S3, and a private caregiver (PC) were on site during the incident. MCD stated he/she interviewed S2, S3 and PC. S2 and S3 stated they did not see S1 pinched and slapped R1's face. PC stated S1 pushed food to R1's mouth. MCD stated S1 reported to him/her that R1 refused the medication after retried during the incident time period. MCD stated he/she helped to administer medications to R1 after received S1's report. LPA interviewed staff S2 and S3. Both stated they were on site during the incident but did not see S1 pinched and slapped R1's face. LPA interviewed staff S4. S4 stated he/she did not see any incident that staff pinching and slapping resident in the facility. LPA interviewed staff S5. S5 stated he/she evaluated R1 for admission. S5 stated R1 has neurocognitive impairment. LPA interviewed S1 on the phone. S1 stated R1 eats meals by himself/herself. S1 stated he/she never feeds R1 food. S1 stated he/she tried to administer medications to R1 but R1 fused to take medication. S1 stated he/she reported to MCD and MCD was able to administer medications to R1. S1 stated he/she continued to administer medication to other residents after the incident. LAP interviewed resident R1. R1 has neurocognitive impairment. R1's answers were conflicting. LPA did not observe bruise, injury, sign of abuse on R1. LPA interviewed 3 residents (R2 - R4). 3 out 3 residents stated they never saw or heard staff pinching or slapping resident's face. Continue on LIC9099-C. Page 2 of 3. LPA interviewed R1's family member (FM). FM stated he/she visited R1 on the that day of the incident from 1:30PM to 3:00PM. He/she did not see any bruise, injury or sign of abuse on R1. FM stated R1 did not complain anything to him/her. Based on the review of R1' physician report dated 9/13/2023, R1 has neurocognitive impairment. On 9/30/2024, LPA interviewed Administrator (ADM). ADM stated the facility final internal investigation finding is unsubstantiated, meaning the facility cannot prove the incident did happen or did not happen. ADM stated the facility notified staff S1 on 11/10/2023 and S1 came back to work on 11/10/2023. ADM provided a copy of the facility internal investigation finding report. ADM stated S1 was working for the facility until 6/1/2024. ADM stated resident R1 still lives in the facility. Based on the review of R1's appraisal needs and service plan dated 1/25/2023, R1 has neurocognitive impairment. Based on the review of law enforcement task force report dated 11/09/2023, R1 was unable to answer the questions. No injury was observed on R1. Based on the interviews and records reviewed, no evidence to indicate that facility staff pinched and slapped a resident's face. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED . An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. This report was provided to review and for signature. A copy of this report was provided to ADM. Page 3 of 3.