Incident investigation·November 25, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to follow up on incident report submitted to the department on 11/19/24. LPA met with Maria Quizon and explained the reason for the visit. On 11/19/24, facility submitted incident report to report the following incident: On 11/18/24, staff heard a scream from Resident #1's(R1) room. When staff enter the room, staff observed Resident #2(R2) in R1's bedroom. R1 stated R2 had thrown a picture frame and hit R1. R1 was bleeding between the nose and forehead. Paramedics were called and R1 was taken to the hospital. Pasadena police department responded to the call with paramedics and provided report #CUS0135. Interviews conducted with staff revealed R2 has had aggressive behaviors towards staff. However, has not shown aggressive towards other residents. LPA attempted to interview R1-R2 but was unable to interview due to cognitive skills. R2 returned to the facility on 10/29/24 after being in skill nursing since July 2024. Documents reviewed revealed R2 has a history of aggressive behaviors. No incident reports were noted for aggressive behaviors between April - June 2024. Needs and care plan has been updated to note change in medication on 11/11/24. Facility staff updated sound device sensors in R1 and R2 bedrooms to increase awareness of the whereabouts of residents. Staff do hourly checks on R2 when R2 chooses to stay in bedroom and if R2 leaves the room staff are notify by the sound devices place near the bed and door and respond immediately. No deficiencies were noted during this visit. Exit interview was conducted and a copy of this report was provided.