Complaint·December 6, 2024

Regarding: Due to a lack of supervision, resident was assaulted by another resident multiple times while in care. R1 was assaulted by R2 on 07/24/24 in the dining room with a fork. The two sat together at a specific table and were regular dining companions.  In order to prevent future incidents, the ED removed their dining table and had staff redirect the two residents to sit with different dining companions. The second assault occurred at 7:30 AM on 08/04/2024. The following was learned through interviews conducted by this LPA and the Ombudsman (O1). This second assault was witnessed by kitchen staff (K1). K1 stated that a dietary aid (D1) saw R2 and R1 arguing at a table. D1 said they moved R2 to another table and as R2 did so, R2 hit R3 in the head.  R3 went to the lobby to tell someone in charge and another member of the kitchen staff (K2) took R2 to a table in the back of the dining room. The responsible party (RP) for R1 was notified of this incident at approximately 9:39 AM by S7. The RP was told R1 was moved to the Sun Room and that they were doing fine. The RP said that they were on their way.  RP and their spouse arrived at approximately 10:30ish and found that R1 was in the Sun Room with 5 other residents, one of them being their attacker.  There were no staff present in the room. According to an interview with O1 on 08/07/24, when O1 spoke to the ED regarding the monitoring of R2, the ED stated that no one was assigned one-on­one to watch R2 despite his assurance R2 would be monitored. When asked why no staff was in the dining room where and when the assaults occurred, the ED stated they were outside the room getting residents ready to go into the dining room. When this LPA interviewed the ED on 08/05/24 as part of a case management regarding the first assault, the ED stated that they would increase monitoring of R1 and R2 and keep them separated.  For meals, he said that most residents were escorted to the dining room. Because care staff were assisting residents from their rooms to the dining room, the residents in the dining room were left unsupervised r esulting in multiple assaults of R1 and R3. The standard for the preponderance of evidence has been met and the department finds the above allegation to be SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC 9099D page. Regarding : Facility did not put a plan in place to protect a resident from being physically attacked by another resident. During the case management visit that took place on 08/02/24, regarding the first assault that occurred on 07/24/24, the ED's plan was to separate R1 and R2 by ensuring that they were not seated at the same table during meals and to increase monitoring. The ED removed the table entirely and used its absence as a justification for seating the two residents at separate locations with new dining companions.  When this LPA visited the facility on 08/05/24, kitchen staff had replaced the table to the original floor plan. The ED immediately removed the table. On 08/07/24, R1 was assaulted by R2 again in the dining room. This LPA learned through a review of records that R2 had 4 "Stop and Watch" communications on file for the following dates: 12/08/23, 12/09/23, 01/21/24, and 02/19/24. They described various incidents and/or attempts of aggressive behavior by R2 towards other residents.  Based on the documentation reviewed, R2 required additional monitoring in order to maintain the safety of the residents in care.  After the assault on 7/24/24, the ED stated that the facility would increase monitoring.  If there had been a monitoring plan put in place, then the assaults on R1 and R3 would not have occurred, however the dining room was left unattended by care staff and 2 residents were struck by R2. The standard for the preponderance of evidence has been met and the department finds the above allegation to be SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC 9099D page. No other deficiencies were observed or cited during today's visit. A copy of this report along with APPEAL RIGHTS were provided. Exit interview.