Incident investigation·February 21, 2024

On February 21, 2024, Licensing Program Analyst, Manuel Monter conducted an unannounced case management visit. The purpose of this case management is regarding an incident that occurred on July 2, 2023, where R1 grabbed a fork and stabbed R2 on the forehead. On July 28, 2023, the Department received an incident report regarding resident R1 assaulting resident R2 around 12pm. R2 was taken to the hospital and has returned to the facility. As a result, R1 was arrested. On August 01, 2023, the Department conducted a preliminary case management visit to get residents R1 and R2’s documents. LPA also requested facility staff schedule and progress notes. On August 28,2023 the Department interviewed resident R2, Staff S1-S3, and Administrator (ADM) regarding the altercation that occurred on July 2, 2023. Based on the Department’s investigation, while staff S1 was about to serve food to the residents, S1 noticed that resident R1 and R2 were arguing at the dining area during a mealtime. S1 saw that R1 got a fork and stabbed R2 on the forehead. S1 stated that ADM was close by and grabbed R1 by the hand that was holding the fork to prevent the assault from continuing. S1 was also grabbing R1’s other hand at the same time. S1 stated staff S2 and S3 assisted as well once they heard the commotion. R2 confirmed that either S1 or S3 were present in the area and staff members pulled R1 off of him/her. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the Department has found that the allegation of neglect/lack of supervision were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited during today’s visit. A copy of the report was provided to ADM.