Incident investigation·September 13, 2022

Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Administrator Kari Oxford & Business Office Director (BOD)Tony Ibarra. The purpose of this case management inspection is to follow up on three self reported SOC 341's submitted to Community Care Licensing (CCL). CCL received 3 SOC341's on 9/7/2022 regarding a dementia resident (R1) and three separate situations that all took place on 8/30/2022. LPA obtained additional information regarding the first incident that took place on 8/30/2022 at 3:45 pm where R1 was witnessed by S1 touching and grabbing resident (R2) over clothing. R2 was assessed and does not recall incident as R2 also has dementia. Second SOC 341 reported, occurred shortly after at approximately 4pm on 8/30/2022. R1 was observed by care staff approach table of R3 & R4 who were eating dinner and R1 started yelling. R1 hit R4 on right arm & R3 on the back. R1 was redirected by S2. Both residents were assessed with no injuries. The third incident occurred at aprox 4:45 PM on 8/30/2022 while S2 was passing meds, R1 refused meds, R1 was talking aggressively to 2 other male residents and was redirected by staff. Staff called BOD who re-directed R1 to patio. BOD escorted R1 back to R1's room, R1 then headed back to hall & followed 2 residents to the TV room. R1 caught up with them and struck R4 in the right arm, BOD interjected and was struck himself. 911 called and R1 sent to Hospital for further evaluation. Per facility BOD, family has contacted and given notice R1 will not be returning to facility.