Incident investigation·November 7, 2024

On 11/7/2024 at 10:24am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a resident to resident altercation. LPA met with Administrator Jagtar Singh and explained the purpose of the visit. LPA also reviewed incident report dated 10-27-24 and conducted a brief interview with Administrator and staff2 (S2). LPA also reviewed physician's reports and needs and services plans for resident1 (R1) and R2. Based on interview and record reviews, on 10-27-24, staff1 (S1) heard screaming within the facility and observed R1 pinching and clawing at R2's face. S1 intervened in an attempt to separate both residents and maintained close proximity to prevent further escalation. Another resident (R3) contacted 911 during the event. While waiting for 911 personnel to arrive R1 engaged in self injury type behavior which consisted of banging her head and face on a table. S1 maintained intervention in attempt to prevent any injury. 911 personnel arrived and took both R1 and R2 to the hospital. R1 and R2 have since returned to the facility with no injuries. The altercation, according to incident report originated over an argument regarding a certain personal item belonging to R1. Administrator has made an appointment for R1 to be evaluated by Psychiatrist. The incident was also reported to licensing department and Ombudsman within regulatory time frames. No citations issued today as a result of this case management. An exit interview was conducted with Celia Nunez as Administrator left premises for a pre-arranged appointment.