Incident investigation·September 26, 2025

Licensing Program Analyst Manuel Monter conducted an unannounced case management visit in regards to a report Department received regarding R1, which occurred on October 18, 2024. LPA met with Administrator James B Mortensen and explained the purpose of the visit. On September 25, 2025, the Department received a report which stated on October 18, 2024, staff S1 had pushed R1, one time, causing R1 to fall from his/her walker and onto the ground, resulting in a laceration to R1's head. S2 stated he/she heard a verbal altercation coming from the hallway. S2 stated when he/she went to see what had occurred, he/she saw R1 down on the ground and bleeding from his/her head. S2 stated he/she went to help R1 but S1 pushed S2 to the ground with two hands. During the visit, LPA interviewed resident R1, Staff S1 and ADM. LPA requested after visit summary documentation for R1's hospital visit after the altercation. . LPA determined this incident requires further investigation. No Deficiencies cited. This report was reviewed with Administrator James B Mortensen. And a copy of the report was provided.