Complaint Investigation Report

Regarding the allegations "Facility staff did not protect a resident from being threatened”, “Facility staff did not protect a resident from being hit", and “Facility did not follow mandated reporter requirements” it was alleged a nurse from an outside agency hit R1 on the shoulder and threatened to kill R1. S1 was present in the room and did not protect R1 or report the abuse properly. Interview with R1 confirmed they were hit and threatened by a home health nurse, not a facility employee. Interview with S1 revealed they witnessed a home health nurse provide care to R1. S1 did not witness any abuse or threats, therefore S1 made no report of abuse. Interview with N1 revealed they did not abuse or threaten R1. R1 told N1 they had shoulder pain, so N1 made sure to stay away from the hurt shoulder. Interviews with twelve (12) out of twelve (12) residents interviewed revealed no residents witnessed or experienced abuse from staff. Interview with the administrator revealed they have not received reports of abuse from any residents. All staff have been trained as mandated reporters to report abuse. Record review of R1’s home health notes revealed no information about abuse or threats made towards R1. During facility tours on 04/17/26 and today, LPA observed staff treating residents respectfully. Based on observations, interviews, and record review, there is insufficient evidence to confirm the validity of the allegations. Therefore, the allegations are deemed UNSUBSTANTIATED at this time.

No immediate health or safety concerns observed during today’s visit.

Exit interview conducted. Copy of report provided.