Complaint·May 19, 2025

On the allegation, " Staff did not prevent resident from harming other residents in care" it was reported that three memory care residents were in a common hallway when Resident 1 (R1) became upset and lunged at Resident 2 (R2) causing them to fall and then R1 punched Resident 3 (R3). On 05/15/25 Administrator Christian Castillo called LPA Cortez to notified them of the incident and left a voicemail. On 05/16/25, LPA Cortez interviewed Administrator Castillo telephonically regarding the incident. Administrator Castillo informed the LPA that R1 had no history of aggression at the facility, there was staff present when the incident occurred, and law enforcement, resident's family member's and other appropriate agencies were notified. The Administrator further stated that they are working with the residents to ensure their safety, and provided R1 a 1:1 for the first 12 hours after the incident as a precaution. Per R1's Physician's Report dated 06/28/24, R1 had listed diagnosis of Mild Cognitive Impairment and Benign Prostatic Hyperplasia. The report indicated R1 did not have any inappropriate or aggressive behaviors, is able to follow instructions as well as communicate needs. Communities internal charting notes revealed that R1 had exhibited aggression towards R3 on one other occasion, however staff was present and intervened. Staff interviews revealed that even though R1 has exhibited agitation and verbal aggressive behavior, they had not observed R1 be physically aggressive towards another resident prior to this incident. When residents are exhibiting aggression staff will re-direct, attempt to see if activities will help the resident, monitor them, report it to their family and physician and suggest a medication evaluation. Staff interviews also revealed that staff was present when the incident occurred, the residents were in the staff's line of sight, staff does not believe anything could have prevented the incident as R1 did not show any alarming behavior prior to the incident, staff intervened as soon as they could and re-directed R1. Furthermore, staff interviews revealed that the community has addressed R1's agitation and aggressive behaviors with family and physician. R1 was interviewed and does not recall pushing or punching anyone. R1 revealed that they do not know who R2 is and that their relationship with R3 is good. R2 declined to be interviewed and R3 was not available for an interview. During today's visit the LPA observed R1 and R2 interacting amicably. Based on the information obtained, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.