complaint·July 6, 2023

Allegation: Lack of supervision resulting in resident being struck/hit while in care. It is alleged that a resident in the Memory Care Unit physically assaulted another resident. Based on interviews conducted and record review, on June 26, 2023 at approximately 8:30 PM, resident (R1) and resident (R2) were sitting next to each other and resident (R1) became agitated by resident (R2's) humming and tapping behavior; subsequently hitting resident (R2) at least three times in the upper head area. Per staff interviews, resident (R1) has history of minor altercations and at times aggressive and threatening behaviors towards residents and staff. In recent months, resident (R1's) aggressive behaviors have worsened. Family has been contacted and the resident is awaiting to be seen by a specialist medical professional. A total of four (4) staff were interviewed whom denied the allegation by stating that the Memory Care Unit has at minimum two (2) staff at all times. On the date of the incident there were three (3) staff on NOC shift. A staff was present when R1 hit R2, but due to R1's impulsive and aggressive behavior staff were unable to prevent the incident. Resident (R1) was interviewed, they confirmed that R2 was hit lightly in the forehead area after "horsing around". Resident (R2) was unable to recollect the incident. A total of six residents were interviewed, two (2) out of six (6) residents reported that R1 gets aggressive and has hit residents in the past. However, due to cognitive impairment of both, residents (R1 & R2) and sufficient staffing at the time of the incident, there is insufficient evidence to corroborate the allegation. Based on record review and interviews conducted there is insufficient evidence to prove the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted Administrator Diana Bautista. A copy of the report was issued.