complaint·March 12, 2025

Record review revealed that on March 4, 2025, the Executive Director of the facility self-reported this witnessed incident to the Department. Per record review and staff interviews, on March 2, 2025, at approximately 2:20 PM, R2 was receiving assistance from Staff #1 (S1) getting off the elevator with their walker. R1 was in their electric wheelchair waiting to exit the elevator when they got frustrated with the amount of time R2 was taking to exit so they slapped R2 in the back open handed twice. During this incident S1, while assisting R2, asked R1 to be patient as R1 was vocalizing their frustration. Once R1 hit R2, S1 immediately intervened and separated the two residents. Per interview, the two residents were exiting the elevator to attend an activity. While both residents still attended the activity, staff ensured they sat on opposite sides of the room and supervised the two residents during the activity. The residents did not interact after the altercation. Per staff interviews, S1 assessed R2 for injuries and inquired about how they were doing. R1 was then interviewed by Staff #2 (S2) to which they admitted to hitting R1. R2 was interviewed shortly after but could not recall the incident due to baseline memory loss. Record review and interviews revealed that local law enforcement was notified, and the facility notified the appropriate parties of the witnessed incident between R1 and R2. Review of R1’s medical assessment records dated September 29, 2023, revealed that R1 had a diagnosis of arthritis, was not confused or disorientated, and did not exhibit inappropriate or aggressive behaviors. Review of R1’s individual service plan report did not reveal any specialized observation requirements. Staff interviews revealed this incident was R1’s first physical incident with another resident. Review of R2’s individual service plan report dated December 17, 2024, revealed R2 needs a one person assist with mobility to escort them to meals and activities. Interview with S1 verified this need for R2 and thus explained their presence for the altercation between R1 and R2. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that the facility’s neglect/lack of supervision resulted in a resident-on-resident altercation. Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director Ortega, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.