Incident investigation·January 21, 2025

On 1/21/25 at 10:00 AM, Licensing Program Analysts (LPAs) Angelica Segovia and Gary Tan conducted an unannounced visit to the facility to conduct a Case Management visit. LPAs were greeted by Executive Director Katherine Aleman. LPAs stated the reason for their visit. The purpose for the visit was to follow up on a self-reported incident (1-13-25) which alleged that Resident 1 (R1) was involved in a physical and verbal altercation with Staff 1 (S1) on 1-10-25. LPAs requested census, staff, and resident Rosters at 10:15 AM. LPAs reviewed pertinent documents from 10:20 AM-12:30 PM. A physical plant tour was conducted at 12:35 PM. LPAs interviewed staff members and Resident 1 (R1) from 12:50 PM to 2:30 PM. Interview with R1 revealed that they had called down for their medication request around 3:30 PM. R1 stated they waited, and no one came to their room until 6:30 PM. R1 stated they were upset because they wanted their medication for pain. R1 stated they suffer from frequent migraines. LPAs record review revealed that R1 had a PRN medication for pain every six (6) hours and the last PRN pain medication administered to R1 was at 12:00 PM and the next one is not due until 6:00 PM as this is a narcotic pain medication. During the medication pass conducted to R1 at own room by Staff #1 (S1) at around 6:30 PM, R1 stated that there was a physical altercation with S1 as R1 argued that S1 was late in giving R1’s medication. An altercation ensued when R1 initially refused medication and S1 allegedly tried to grab R1’s medication on R1’s hand resulting to scratches on R1’s hands. LPAs record review and interview with the Executive Director (ED) revealed that ED talked to R1 by phone at around 8:28 PM and R1 told ED that R1 was okay when R1 mentioned he had a cut on their hand. At 9:31 PM, however, the ED received a picture from R1 showing a fresh scratch on R1’s hands. Record review showcased that R1 has a history of false reporting, self-inflicting wound, and aggressive behavior. During the interview with S1, S1 denied having any physical contact with R1. Based on LPAs’ record review and interviews, there is not enough information to prove that S1 physically hurt R1. No further actions needed at this time and no immediate health and safety issues observed during this visit. Exit interview conducted. A copy of this report was given to the Executive Director.