Incident investigation·April 30, 2026

On April 30, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit. On April 27, 2026, the facility reported that on April 22, 2026, during lunch, staff witnessed resident #1 (R1) grabbed resident #2 (R2)'s lunch and R2 attempted to stop R1 and threw water and juice at R1. The incident report states that staff were able to redirect both residents and calm them down. During today's visit, LPA interviewed staff, interviewed R1, observed R2, and reviewed documentation. According to S1 who witnessed the incident stated that both residents were separated immediately and there was no injuries noted to both residents. In addition, S1 and staff #2 (S2) stated that since the incident, they are monitoring both residents more closely during mealtimes and there were no other incidents occurred. According to the Regional Memory Care Director, R1 and R2 continued to sit together during lunch as their preference, and they tried different methods to have them sit separately but they refused. Therefore, facility staff continued to monitor them closely. LPA interviewed R1 who appeared to be pleasant and did not remember the incident. LPA attempted to interview R2 but R2 was sleeping in the room. Based on documentation, R1 and R2 did not sustain any injuries due to the altercation. No deficient is cited. This report is reviewed and discussed with the administrator and a copy is provided.