complaint·June 28, 2024

Interview with R1 at 10:20 a.m. today revealed R1 and R2 were arguing and R2 lightly hit R1 in the arm five (05) to six (06) times. R2 then called R1 a derogatory slur and R1 slapped R2. R1 stated they had not fought before and no longer intend to fight. R2 “always wants to start stuff” with R1. R1 also admitted they are confused, struggle with mental stability, and take medication for the problem. R1 could not recall if staff intervened. Interview with R2 at 10:35 a.m. today revealed they did call R1 a derogatory slur and R1 slapped R2. R2’s partner Resident #3 (R3) called the police. R2 stated R1 was always in the hallways “looking for a fight”. R2 also stated no staff intervened and they do not feel safe living at the facility. The assistant administrator held a meeting with R1 and R2 the following day and instructed the two to stay away from one another. Interview with Staff #1 (S1) at 10:45 a.m. today revealed they were in the TV room when they had heard R1 and R2 arguing in the dining room. S1 ran over and saw R1 with their hands on R2’s wheelchair and R1’s face very near R2’s face. S1 put their body in between R1 and R2. R1 then slapped R2, and R2 slapped R1. S1 separated the two residents afterwards. Interview with Staff #2 (S2) at 10:10 a.m. today revealed staff are trained to place their hands and arms between residents to break up fights. Interview with the assistant administrator revealed R2 had a history of using derogatory slurs and starting fights. During the meeting between R1 and R2 and the assistant administrator on 06/23/24, the police’s instructions for the two to stay away from each other were reiterated. The assistant administrator also stated the facility has scheduled staff training with their consultant group for all residents with known behavioral issues. It was stated that the service plans for R1 and R2 were not updated to address their arguments and altercations. Record review at 12:00 p.m. today revealed R2’s service plan noted the facility “will observe for mood changes, agitation... signs of anxiety”. R1’s service plan noted the facility “will observe client daily for mood changes, apathy, aggression, agitation". Based on interviews and record review, facility staff did not intervene in time to prevent an altercation between R1 and R2. Therefore, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on the attached LIC 9099-D page. No immediate health and safety risks were observed during today's visit. Exit interview conducted. Appeal rights discussed. Copy of report provided.