Complaint Investigation Report

Allegation: Resident was physically abuse while in care.

The details of the complaint alleged that (R#1) was physically attacked by (R#2).

On January 18, 2026, during a comprehensive records review, the department examined facility progress notes for (R#1) dated 9/25/24. The department observed that on 9/25/24, the day of the alleged abuse, facility staff found (R#1) face down on the floor without underwear and appearing to be under the influence. Staff noticed blood on (R#1) but could not locate the source, as no open wounds were visible. Due to (R#1)’s condition at the time, staff could not conduct a proper assessment. They promptly called emergency services, and (R#1) was transported to the emergency room. The progress notes contained no documentation indicating that (R#1) reported being physically attacked by (R#2). Moreover, the department observed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A, dated 2/27/25. Under the physical health status, it is noted that (R#1) has mild cognitive impairment and uses alcohol.

On January 17, 2026, at approximately 10:30 AM, the department interviewed (A#1), who provided his statement regarding the allegation. He stated that when the facility became aware of the alleged physical assault on September 29, 2024, staff immediately moved (R#1) to a different room and initiated an internal investigation. The investigation concluded that (R#2) did not physically abuse (R#1). There were no reports from any facility staff indicating they heard or observed an altercation between (R#1) and (R#2) at the time of the incident. Following the allegation, the facility interviewed (R#2) and determined there was insufficient evidence to substantiate the claim. The facility reported implementing measures to ensure resident safety during the investigation process.

On January 17, 2026, at approximately 11:00 AM, the department interviewed (R#1), who stated that their interaction with their former roommate (R#2) was minimal, as they were simply roommates. When asked if (R#2) had ever physically abused them, (R#1) responded that (R#2) did not touch them at all.