complaint·March 21, 2025

During the investigation, through record reviews, and interviews, the Department established the following sequence of events. Based on staff statements, on December 23, 2024, at or around 4pm, R1 was heard calling R2 derogatory names then R2 hit R1 in the face, which resulted in a cut and bruising to R1’s face. According to multiple staff, R1 and R2 were separated and R1 was provided first aid while emergency personnel arrived. At this time, R1 was taken to receive medical care and R2 was sent to a psychiatric hold for a safety evaluation. While both residents were away, Wellness Coordinator requested R1 and R2’s Primary Care Provider to re-evaluate both resident’s medications but such changes were denied. On the same night of the incident, both R1 and R2 were discharged back to the facility. On this date, there were three staff present to intervene in the incident, provide first aid and contact emergency personnel. According to outside source records, on this date R1 was diagnosed with an abrasion to the forehead and contusion of the forehead. The investigation also found that on December 24, 2024, at or around 4pm, R1 was heard calling R2 the same derogatory names and R2 hit R1 in the face multiple times. Staff present established that the altercation was heard, and multiple staff assisted in separating the two residents. On this date, emergency personnel were contacted but only medical assistance arrived. R1 was then taken to receive medical care. Outside source records collected revealed that this incident resulted in R1 having a cut to the scalp as well as a hematoma, but no fractures were found. According to interview with the Wellness Coordinator R1 and R2’s rooms are now in different parts of the same building; their meals are served in different locations and there is additional supervision to both residents. R2 has since received medication to assist with agitation. Based on a review of pertinent records and interviews, the preponderance of the evidence standard was not met to prove staff neglect and/or lack of supervision resulted in resident-on-resident altercation with injury. An exit interview was conducted with Executive Director Jonathan Wheeler, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.