Incident investigation·November 15, 2021

On November 15, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced Case Management visit regarding an Incident Report that was received on November 10, 2021. LPA was greeted by the Administrator, Joan Newman and the Director of Health Services, Glynis Marcantel joined shortly thereafter. LPA Charitra explained the purpose of the visit During today's inspection LPA observed the residents. Residents were observed to be in the dining room together at this time. LPA interviewed staff and reviewed resident documents and the admission agreement. According to the admission agreement, the residents are able to remain independent, roam around the facility and actively engage in the community alone. According to the Incident Report, Resident 1 (R1) was observed to be kicking Resident 2 (R2). Residents have a diagnosis of Dementia with Behavioral Disturbances and were left alone in the dining room when the incident occurred. Based on the Administrator and the Director of Health Services, this was a one time altercation between the residents, no prior history of physical abuse. The facility does not provide one on one care to the residents unless stated otherwise. LPA reviewed the Needs and Service Plan for both R1 and R2 and it states residents do not require hands on assistance. Facility informed Ombudsman, Licensing, Physicians, and the resident's Responsible Party regarding this Incident. No deficiencies were issued. Report was reviewed with Administrator