Complaint·July 11, 2025

It was the first documented case of aggression between the residents and measures were promptly implemented to prevent a recurrence. Through interview with R1, it was discovered that they initiated the altercation with R2 due to discomfort caused by R2’s smile and loud outburst. R1 shared that the staff quickly intervened to de-escalate the situation and medical attention was provided after R1 reported experiencing pain. Interview with R2 stated that they acknowledged making a statement to R1 that led to the incident. Additionally, R2 described the incident with R1 as an accident and reported that staff quickly responded to de-escalate the situation. Through interview with Additional Witness 1 (AW1), it was revealed that they were made aware of the incident by R1 and subsequently discussed preventive strategies with the Administrator. AW1 stated that they followed up with R1 and no further altercations have occurred with R2. AW1 stated they had no further concerns regarding staff’s intervention or engagement with residents. Additional interviews with residents reported no concerns regarding staff not preventing altercations between residents. A record review confirmed that facility staff had completed training in incident reporting, as well as in de-escalation, and behavioral management techniques. Based on observation, record review, client, and staff interviews, the allegations that staff did not prevent an altercation between residents resulting in resident's injury is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided to facility representative.