Incident investigation·March 6, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on (2) incident reports received. LPA met with Marjorie Reboja, Administrator, and stated the reason for today's inspection. A required annual inspection was also conducted today. LPA and Administrator discussed the following incidences between residents (R1 and R2), as follows: On February 6, 2025, (R1) hit (R2) in the face after (R2) allegedly annoyed (R1) in their shared room. Neither resident was injured and the Administrator spoke to each resident about the reason for the occurrence. On February 13, 2025, (R1) hit (R2) again in the face after both residents were arguing with each other. The same day, (R1) moved to a private room and (R2) moved to a shared room with another resident. There have been no subsequent incidences since. The Administrator talked to both resident's responsible persons, and they agreed with the room change. They had only been roommates for about (2) weeks when the first incident happened. Administrator took (R1) to the emergency room following the second incident. (R1) was evaluated and returned the same day with no medication changes. (R1) has a diagnosis of Dementia. Administrator will update his care plan (due 3/19/25) and include these incidences. Administrator will continue to monitor them and let the families and Department know if there are any future incidences. There are no deficiencies cited in this report. Exit interview. Copy of report provided.