complaint·September 5, 2023

Interviews with residents revealed 8 out of 10 residents stated to not have experience verbal arguments with other residents. Residents stated to feel safe, and that staff will aid right away to a situation like that. 1 out of 10 residents was unable to be interview due to cognitive skills. 1 out of 10 residents stated to have been verbally threaten by another resident and that initially had requested to stay in the room as did not feel the other resident could be harmful. R1 stated staff move R1 to another room the second time R1 mentioned the situation to the staff the same day. Interviews with staff revealed the following: On 7/6/23 R1 moved into room #233 and was alone until roommate returned from the hospital. On 7/27/23 R1 was moved to room #209 per R1’s request as he stated not to be able to sleep due to new roommate. R1 resided in room #209 for some weeks without concerns. About a week before 8/27/23 R1 stated to assistant administrator not being able to sleep due to R2 talking and giving verbal threats at that time R1 was giving the option of moving to another room. However, R1 stated to want to stay in that room. The second time R1 brought up the situation on 8/27/23 in the morning, staff acknowledged R1 and told R1 a different room will be assigned for R1 that night. R1 was moved to room #228 on 8/27/23 before the end of the day. Per document review, R2's physician's report dated 4/22/23 does not note any aggressive or inappropriate behaviors. Both residents have individual services plans in place. Clinical Flex notes noted incident on 8/27/23 which provide the communication between R1 and staff and the determination of moving R1 to a different room the same day before Pasadena police officer arrived at the facility the afternoon of 08/27/23. No history of previous incidents was noted on either residents file. Incident report was not available for review at the time of the visit or submitted to the department within the required 7 days. Although the situation may have happened facility staff address the situation and provided alternative room for R1 upon being presented to the staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.