Complaint·October 17, 2024

Lack of supervision resulted in Resident on Resident Altercation: The allegation is that facility staff lack of supervision resulting in on 4/10/2024 around 3:30PM, a resident R1 wandering into another resident R2's room and having alteration between R1 and R2. Both R1 and R2 live in the memory care unit. On 4/19/2024, LPA interviewed Executive Director (ED) Joyce Welch. ED stated on 4/10/2024, resident R1 entered resident R2's room. R1 has neurocognitive impairment and thought that is R1's room. R2 asked R1 to leave the room and R1 got mad. R2 has a private companion (PC1) at that time. PC1 stated R2 told PC1 that R1 attacked R2 but PC1 stated he/she did not observe it. LPA interviewed PC1. PC1 stated he/she was in the restroom when the incident occurred. PC1 stated he/she did not see R1 attacked R2 but he/she saw R1 in R2's room when he/she exited from the restroom. PC1 stated he/she asked R1 to leave R2's room. LPA interviewed resident R2. R2 has neurocognitive impairment. R2 stated he/she cannot recall the incident. R2 stated the facility has a good environment to live. R2 stated he/she likes the facility. LPA interviewed Wellness Director (S1). S1 stated R2 has private companion from 6:00AM to 6:00PM Monday to Saturday. S1 stated on 4/10/2024, he/she received a report that resident R1 entered resident R2's room and R1 and R2 had altercation. S1 stated he/she went to R2's room immediately and R1 already left R2's room. S1 assessed R2 immediately. S1 stated he/she did not find any injury on R2, and R2 stated he/she is fine. S1 stated he/she notified Police, Ombudsman, CCL office and resident families immediately. S1 stated after the incident, the facility provided a week's staff training to prevent the similar incident to occur. R1 moved in the facility on 4/2/2024. R1 did not have similar incident before during 9 day's stay in the facility. Based on the review of R1's Pre-Admission evaluation document dated 3/17/2024, R1 has neurocognitive impairment, elopement, exit seeking/wandering and needing occasional intervention. Based on the review of the LAW Enforcement Task Report, the R2 had no visible injuries. and this is the R1's first incident. Continue on LIC9099-C. Page 2 of 3. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citation noted today. Exit interview was conducted with ED. A copy of the report was provide to ED. Page 3 of 3.