complaint·October 25, 2024

Per review of monthly staff schedule, LPA verified the facility had sufficient staff coverage to meet the care and supervision needs of each resident. The facility had four (4) caregivers and one (1) med/tech to 36 residents at the time of the incident. LPA conducted an interview with R1 regarding the alleged incident. During the interview, R1 recounted while they were walking through the hallway carrying their lunch plate, R2 suddenly and unexpectedly launched an aggressive attack on R1. R1 expressed surprise and confusion, noting they had no prior familiarity or interactions with R2. The commotion created by the incident drew the attention of two caregivers who were providing care to other residents nearby. The caregivers intervened and managed to re-directed R2, successfully preventing any further harm to R1. LPA also attempted to interview R2; however, R2 was unable to communicate due to their health condition. LPA reviewed supportive documentation which detailed the resident-on-resident altercation and confirmed the incident was self-reported by the facility as per regulatory requirements. A review of the staff schedule confirmed there was sufficient staffing in numbers to provide care and supervision necessary to meet residents’ needs at the time of the incident. Based on the interviews conducted, record reviews, and the verification of staff schedules, LPA determined the allegation that due to lack of supervision, a resident got into physical altercation with another resident is Unsubstantiated . A finding of Unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided. ***This is an amended version of the report created on 10-25-2024.