Incident investigation·May 11, 2023

On 5/11/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of conducting a case management to follow up on several incident reports and SOC341 Reports of Suspected Abuse submitted by the facility. LPA was greeted by Lead Staff, Ollive NeSmith and continued with discussing the facility's actions to the incidents. Service Coordinator, Danvie Cardano arrived later in the visit. The report indicated resident (R1) responsible for altercations between four other residents resulting in residents (R2, R3, R4 & R5) to have been physically assaulted by R1. The facility had initiated emergency services and transferred R1 to the Napa Crisis Center the day of the altercations on 4/4/2023. LPA was informed that R1 had requested to be discharged from the facility and was placed at a more appropriate level of care. LPA found that R1 had several medication refusals noted in progress notes prior to the incidents and had caused a change of behaviors. No deficiencies cited during today's visit.