During today's visit starting at 10:06 a.m. LPA and DRCS briefly toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards, and facility is in compliance with Title 22 Regulations. Starting at 10:22 a.m. and through the visit LPA conducted five (5) staff interviews, including Staff #1 (S1), interviewed Resident #1 (R1) and obtained copies of pertinent documents relevant to the investigation.

On the allegation, Staff inappropriately sprayed a resident, it is the concern of the Reporting Party (RP) that during a shower S1 sprayed R1 in the face and mouth during a shower. To investigate this complaint, LPA conducted in person staff interviews, in person resident interviews, file and record review, and obtained copies of pertinent documentation relevant to the investigation.

Interview with R1 revealed that on the alleged incident date of 03/17/2026, during the morning, S1 assisted them with a shower. R1 reported that they were unfamiliar with S1, which was unusual because they are typically familiar with the PALs in the community. They stated that they do not recall what the staff member looked like or their name, noting, “It all happened so fast.”

R1 explained that they have sensitive eyes and ears, and water in those areas bothers them. During the assisted shower, they stated that S1 sprayed water into their face and ears. R1 reported, “They didn’t say anything or apologize,” and expressed that while they understand it was a shower, certain areas—specifically the eyes and ears—should be shielded. They described the interaction as rude, and not accidental.

R1 stated that they have never had an encounter like this with a PAL before. They shared that “The PALs will bend over backwards to do things for you; they are great.” R1 confirmed that they have not had any additional interactions with S1 since the incident.

Interviews with residents revealed that they have not experienced any negative interactions with the PALs during showers. Residents reported satisfaction with the quality of care provided and stated that staff consistently treat them with dignity and respect during bathing assistance. Residents indicated that they are only minimally familiar with S1, noting that they have seen them briefly in the community. Several residents believed that S1 is new to the community, which may explain their limited familiarity.

Report continued on LIC 9099-C PAGE 3...

Interview with S1 revealed that on the day of the alleged incident, 03/17/2026, they assisted R1 in getting out of bed. R1 appeared to be struggling to wake up that morning, and the med tech reminded S1 that R1 had an appointment. S1 stated that R1 was cooperative throughout the interaction. S1 assisted R1 to the toilet, then proceeded with the shower, prompting R1 to close their eyes while washing their hair, and completed the shower without issue reported at the time.S1 stated that they “did not act with bad intentions at any point” and believe the situation may be a misunderstanding. Additionally, S1 reported that at no time did R1 verbalize any discomfort or dissatisfaction during the shower. S1 emphasized that they had no ill intent, have never received complaints regarding showers in the past, and were unaware that R1 had any concerns until the allegation was brought forward.

Staff interviews revealed that they treat residents with dignity and respect, prioritizing resident safety. Staff reported that they have not received any complaints regarding dissatisfaction during showers; however, they stated that if a concern were to arise, it would be reported to the DRCS immediately. During interviews, staff demonstrated knowledge of resident rights, the different forms of abuse, and reporting procedures.

Interview with the DCRS revealed that on the day of the alleged incident 03/17/2026 they received an email from R1’s Power of Attorney (POA) detailing the incident. Once the facility became aware of the allegation, staff followed protocol and initiated an internal investigation. The appropriate agencies, including Licensing, Ombudsman, and Sheriff’s department were notified. The staff was removed from the schedule and was interviewed regarding the allegation and denied any aggressive actions during the shower. It was reported that the staff reported that nothing inappropriate occurred and denied spraying water toward the resident’s face. The staff was removed from the schedule, and will not be placed back on the floor. The staff is redoing all their PAL training and any components included in the initial orientation training. In addition, they will complete 3–4 days of buddy training/shadowing with a lead med tech or caregiver. Following the complaint, the nurse spoke with the resident. The resident stated that the PAL sprayed water into her face and ear. When asked if it might have been accidental, the resident said they did not believe it was. The resident denied pain or injury. A visual assessment was completed, revealing no injuries, and the resident was stable at baseline. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff inappropriately sprayed a resident is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.