Incident investigation·March 19, 2024

On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management visit to follow up on an Incident that occurred on March 14, 2024. LPA discussed purpose of visit with Administrator Erin Rehbein. On March 19, 2024 Department received a Self reported SOC 341 Report from Facility. Facility reported that an incident occurred between two residents on March 14, 2024. Staff reported to Administrator that in passing in facility hallway, Resident 1 (R1) approached Resident 2 (R2). Staff reported that R2 was rubbed by R1 on the right side thigh and butt area. Staff also reported that same incident occurred a second time on March 16, 2024. Upon learning of incident Administrator had staff member (S1) translate to R2 regarding incident. Based on translation S1 stated that they asked R2 if they were touched inappropriately to which R2 shook their head "no". S1 asked R2 if they were hurt and R2 stated "Ok" in Vietnamese. Based off interviews with staff, Administrator stated that they spoke to R1 regarding incident and R1 claimed they "did not know anything". Facility had sent out R1 to hospital for Psych Evaluation. R1's face sheet, Appraisal, and Emergency info all state that R1 has a health history of Dementia and Schizophrenia. R1's Physician's Report dated November 30, 2023 has diagnosis of Pneumonia, COPD and mild cognitive impairment. At time of visit R1 not present for interview. R1 has not returned to facility. Administrator states upon R1's discharge they plan to work with conservator regarding plan of care moving forward. During visit, with the help of staff 1, LPA attempted interviewing R2 regarding incident, upon attempt R2 nodded head "yes" when asked if they were okay. R2 was asked if they had been touched and R2 nodded "no". R2 was unable to verbally communicate due to a language barrier. LPA observed R2's Physician Report which has Schizophrenia listed as primary diagnosis and lists Cerebral Infarction as secondary diagnosis. R2's Resident's Appraisal dated 11/30/23 states R2 has a communication deficit and unable to communicate needs clearly. CONTINUED ON 809C Administrator contacted responsible parties, Licensing, Ombudsman and Police regarding incident. LPA received copies of resident physician's reports and appraisals. An exit interview was conducted with Assistant Administrator Kathleen Tamondong and a copy of report was left at facility.