Complaint·July 26, 2025

The LPA attempted to interview Resident #2 (R2) who refused to be interviewed or speak with the LPA. The Administrator was advised that further investigation was needed prior to issuing findings. A review of R1’s physician report, dated 01/31/2020, listed the primary diagnosis as diabetes type 2, and secondary diagnosis listed as HTN, bipolar I, atrial flutter, and sinus node dysfunction. R1 was able to leave the facility unassisted. No cognitive impairment was noted. R1’s resident assessment, dated 08/21/2024, listed R1 as independent for bathing, dressing, grooming, toileting, transfer and mobility. R1 required use of cane, walker, wheelchair, diabetic diet, and assistance with glucose monitoring. Chronic pain and mental health services were also noted. No cognitive impairment was noted. Behaviors listed as moderate with daily interventions needed due to disruptive, aggressive, or socially inappropriate behavior. Current depression, anxiety, mood disorder. Requires medication assistance, injections 3 times per day, has a psychiatrist and a case manager. A review of R2’s physician report, dated 02/06/2024, listed the primary diagnosis as Schizophrenia, unspecified. No cognitive impairment was noted. R2 was not able to leave the facility unassisted. R2’s resident assessment, dated 07/10/2024, listed R2 as non-ambulatory, having dementia, behavior impairment, confused, agitated, uncooperative and resistant to care assistance. R2 is conserved by the public guardian. According to the Administrator, the medtech reported on 10/02/2024, 2:00am, they heard loud screaming from R1 and R2 in the activity room, came to check, and separate them when R2 hit R1 on the back of head. Riverside Police Department were called and escorted R2 back to their room. There was no visible injury, but R1 complained of pain, and 911 was called. R1 returned to the facility the same day. The Administrator does not recall if R1 had an injury, and does not know the discharge diagnosis as R1 refused to give the facility any paperwork from the hospital. The Administrator stated on 10/02/2024 the facility census was 105 and the overnight (NOC) shift had two team members working. Both the residents’ physicians were notified. R2’s public guardian was also informed of the incident. Continued on LIC 9099-C. The review of Unusual Incident/Injury Reports (SIRs) and facility notes related to R1 revealed on 10/17/2024, R1 called 911 due to experiencing stroke-like symptoms. R1 had a droopy eye, stated they did not feel like themselves, and complained of pain in their temple. The ambulance transported R1 to the hospital. R1 returned to the facility on 10/22/2024 with a new order of Pradaxa and to follow up with their primary care physician. R1 did not provide any paperwork from the hospital to the facility. On 10/23/2024, R1 reported feeling dizzy and called 911, R1 was taken to emergency room and returned to the facility the same day. R1 did not provide any discharge paperwork to the facility. During the course of the investigation, the Department was not able to obtain an interview with R1. Per the Administrator, R1 moved out of the facility on 11/11/2024 and there is no contact information for R1. The information obtained during the Department’s investigation did not sufficiently support the allegation. While R1 was hit on the head during an altercation with R2, the investigation did not provide sufficient evidence to substantiate neglect/lack of supervision by facility staff. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.