Incident investigation·February 11, 2026

Licensing Program Analyst Manuel Monter conducted an unannounced case management- Incident visit, regarding a SOC341, personal rights violation, regarding resident R1. LPA also subsequently violations issued discovered during the complaint investigation for 26-AS-20250929092054. LPA with Administrator Camille Burke Potential Violation discovered during compliant investigation process 26-AS-20250929092054 During complaint investigation, LPA randomly reviewed residents medications. LPA noted discrepancies with residents R15 and R16 medication records, when reviewing their Medication administration records, Centrally Stored Medication Records and a physical Pill count. At this time, this case in under review and Department will conduct a follow up visit , if warranted. Follow up on incident dated February 9, 2026 On February 10, 2026, the Department received a SOC341 regarding resident R1. R1 has camera in his/her apartment. R1's Family member brought the footage to the facility on 2/09/2026. The video footage showed the following, On February 5, 2026 at around 2.00am, Staff S1 did rounds to check on residents. R1 came to R1's Apartment. S1 approached R1 and woke him/her up to change his/her brief. At first S1 stated to resident he/she wanted to check if his/her brief was wet but resident refused and told S1 to go away. S1 kept insisting to change resident's brief and was persistent in his/her approach to the point resident had increased agitation and became combative. (Continued on LIC809-C) R1 continued to hit, punch and kick S1. S1 kept asking resident to stop hitting, punching and kicking him/her but resident continued shouting and asking S1 to leave him/her alone. S1 brought the wheelchair and placed it along side the bed and in-spite of R1's refusals and combativeness to comply to care, S1 transferred resident to his/her wheelchair after a few attempts, R1 kept screaming for help but S1 took resident to the bathroom and changed his/her brief. S1 then wheeled resident out of his/her apartment to the dining room. R1 was then wheeled back to his/her apartment after some time. R1 was calm at that time and said thank you to S1. LPA requested copies of the following documents: R1's Physician's Report and care plan. R1's Progress notes from December 2025 - February 2026 R1's Emergency Contact Sheet S1's Training records for 2026 and 2025 S1's LIC501 S1's Photo ID At this time, this case in under review and Department will conduct a follow up visit , if warranted. No deficiency noted today. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.