Follow-up·September 14, 2021

On 9/142021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings from a Case Management visit on 8/23/2021. LPA Han met with the Executive Director, Fili Howard and explained the purpose of the visit. The incident happened on 8/17/2021 around breakfast time, when the Medication Technician was preparing medication in the dining room, he/she heard a loud noise and witnessed that R1's right arm was extended upward in a swinging motion and R2 was on the floor. The staff reported that R2 has a tendency of grabbing other resident's foods so when R1 saw R2 attempted to grab R3's food, R1 probably pushed R2. During LPA's visit on 8/23/2021, LPA observed R1 and R3 to be calmed in the dining room and awaiting for their lunch. R1 was sitting at a table and having conversation with another resident. LPA observed several staff members in the room assisting the residents. LPA interviewed R2 and R3 regarding the incident and both of them couldn't remember anything about it. LPA interviewed three caregivers who were in the dining during the incident and they stated did not witness the incident as they were assisting other residents with their meals but they looked up as they heard a loud noise and witnessed R2 on the floor. They reported that R2 has a tendency of grabbing other resident's food and they were trained on how to distract R2 from doing that. After the incident, the facility has updated R1's care plan including medication review to address the recent aggressive behavior. R2 was transferred to the acute hospital for the fall and the facility requested the hospital to perform a medication review prior to discharge due to the recent behaviors. R2 has returned to the facility and the staff members reported that R2 seemed to be calm and comfortable. There is no further incidents. No deficiency is cited today. This report is reviewed, discussed with the Administrator, Fili Howard, a copy is provided.