Incident investigation·March 16, 2022

Licensing Program Analyst (LPA) Hansen conducted an unannounced Case Management visit to the facility regarding an incident & SOC 341 report submitted by the facility on 3/11/2022. LPA met with Lupe Guerrero Director of Health Services regarding the incident that occurred on 3/9/2022 at 9:10 pm between Resident (R)1 and (R)2. LPA interviewed staff, acquired more information, and toured the facility. Prior to incident R1 has been witnessed rubbing R2's neck. As per facility, dining room server reported observing R2 with hands on R1's neck. Staff was able to separate them and R2 tried to throw chairs and turn over tables. After a few minutes R2 calmed down and went to bed. R2's MD called to rule out a UTI. MD ordered additional meds for R2. R2's wife will assist with a 1:1 companion in the evenings. There has never been an issue like this with R2. R1 and R2 have been friends since R2 moved in 9/2021. R1 likes to sit with R2 and thinks this is R1's partner and sometimes they hold hands. R1's wife visits 3-4 times a week and daily this week. R1 continuously tries to sit with R2 but staff redirects R1. Facility is now keeping R1 away from R2. On this day LPA witnessed R1 standing in dinning room 1 area appearing to search for books. R2 was coming out of room with personal 1 on 1 headed to dinning room 2 after 1 on 1 had applied cream on R2's leg. Both residents appeared to be calm. No deficiencies cited during today’s visit.