Incident investigation·January 23, 2024

At approximately 2:00PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection. LPA followed up on an Incident Report that occurred on 08/16/2023 and a self reported SOC341 (Suspected Dependent Adult/ Elder Abuse) that occurred on 12/24/2023. LPA met with Resident Service Director (RSD), Jocelyn Vahle, and discussed the purpose of the visit. Incident Report dated 08/16/2023: Incident Report states that Resident 1 (R1) was found on the floor by staff with a firm art piece next to them. R1's right wrist appeared to be cut in a horizontal direction and there were blood stains on their sleeve close to the wound. Facility called the paramedics and the police department followed. R1 was then transported to the hospital. Per conversation with RSD, after R1 arrived at the hospital they were evaluated by a psychiatrist and they were not placed on a 5150 hold as they did not meet the criteria. RSD had a conversation with R1s family about options for bringing R1 back to the facility with a 1:1 or bringing the resident back to live with their family. Ultimately, family decided to bring R1 back to their family home. R1 did not return to the facility. SOC341 dated 12/24/2023: SOC341 states that Resident 2 (R2) and Resident 3 (R3) are live in partners in the facilities Memory Care unit. R2 was observed to hit R3 with a closed fist on R3's left shoulder. R2 was upset that R3 did not want to get coffee with them. R2 became agitated when staff attempted to redirect them. R2 and R3's families were notified of the incident. Per conversation with RSD, R2 came into the facility with aggressive behaviors that were difficult for staff to manage. After the incident, R2 was taken to the physician by their daughter and it was found that R2 had a Urinary Tract Infection (UTI). R2 then had multiple medication adjustments and staff has seen a decline in aggressive behaviors since their medications have been adjusted and their UTI was treated. R2 has not been observed to be engaging in any inappropriate behavior towards R3 since the incident. Exit interview conducted. Copy of report, LIC811 (Confidential Names), discussed and provided to RSD. Signature on form confirms receipt of documents.