complaint·November 5, 2025

Per information received from interviews conducted regarding the allegation that facility staff did not prevent physical altercation between residents, investigation revealed that on 11/1/25, around 11am/11:30am, just before lunch, Staff #2 was assisting Resident #3 in the TV Room located in Memory Care, when Staff #2 heard Resident #1 and Resident #2 having a very loud verbal fight and profanity was being thrown around by Resident #2 in the dining room. Per Staff #2, they immediately went over to see what was happening and observed Resident #1 drenched in juice. Per Staff#2, they did not observe the juice being thrown or if there were any physical contact between the 2 residents. Both residents were not observed with any injuries or bruises. Staff #2 just observed that Resident #1 was soaked. They stood between the 2 resident to prevent the residents from reaching each other. Per Staff #2, as they are going towards the 2 residents, they called Staff #1 for assistance. Staff #1 arrived immediately and Staff #2 continued assisting other residents with lunch. Per Staff #1, Resident #2 was very agitated, aggressive and yelling at staff and following them. Staff #1 called the family to see if they could come to the facility to calm Resident #2 but the family advised staff that they couldn't until the following day. They did not have a vehicle. Staff #1 called private transportation to send Resident #2 to the hospital but resident refused to be assessed and was very aggressive with the ambulance personnel and refused to comply. They advised staff to call the PET team to have Resident #2 assessed for a 5150 hold. The PET team was contacted around 3pm and due to a high volume of calls the PET team did not arrive until about 6pm that evening with law enforcement to assist. Resident #2, still very agitated, refused to be assessed by the PET team and refused to let the team into their room and attempted to slam the door on them. Eventually, Resident #2 complied with law enforcement's request to get on the gurney and was transported to the hospital for assessment. Resident #2 was diagnosed with confusion, agitation and urinary tract infection. At the time of admission to the facility, Resident #1 was diagnosed with Alzheimer and was admitted to the facility on 10/30/25, without any medications. Resident #2 returned to the facility on the evening of 11/3/25 with prescribed medications and is currently calm. Based on today's investigation, the facility residents do not require one to one supervision and are allowed to mingle with other residents. Staff cannot anticipate when a resident is going to have a behavior but can only be available when intervention is needed. The incident between Resident #1 and Resident #2 was not anticipated and could not have been prevented even if staff were present. Per the investigation, the appropriate actions were taken by staff to mitigate any further harm, therefore the allegation that facility staff did not prevent physical altercation between residents is deemed unsubstantiated at this time. Exit interview was conducted.