Incident investigation·November 7, 2024

On 11/07/2024 at 2:40 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to Community Care Licensing Division (CCLD) on 07/30/2024. LPA met with General Manager (GM), Linda L. Fisher and explained the purpose of the visit. GM, Linda L. Fisher, had to leave and authorized Health Services Director, Davinderjit Singh, to sign the report. On 07/30/2024 CCLD received an Unusual Incident Report (UIR) that reported that Residents (R1) and (R2) were both in a physical altercation on 07/29/2024. The report indicated that R1 was found laying on the floor with R2 standing nearby. The report further indicated that R1 and R2 were in a dispute regarding money that was allegedly removed from R2's room. LPA interviewed S1 that stated the nurse called to check on R1 while on the floor and asked R1 if they had any pain and R1 responded, "yes." S1 stated that they called 911 and R1 was transported to the emergency department for further evaluations at Kaiser Walnut Creek. S1 stated that R1 returned back to the facility, all acute testing came back normal and R1 had a doctor's order for pain management. S1 stated that staff was advised to keep both residents separated. LPA obtained a copy of resident's roster, physician's reports, medication lists and Individualized Service Assessments for R1 and R2. LPA reviewed that R1 has a diagnosis of dementia. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.