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32 | the same day the incident occurred. Interview and record review revealed that R1 moved into the facility on 04/21/2026. At that time, R1's medical assessment indicated no behavioral expressions such as lack of impulse control or expressions of frustration. No aggression was noted in either R1's care plan or medical assessment upon intake. While at the facility, staff had noted additional behaviors not previously identified and as a result, R1 was treated outside the facility from 05/12/2026 to 05/29/2026. Upon R1's return to the facility, staff placed R1 on 1:1 care for 72 hours, per standard protocol. R1's medical team then adjusted R1's medications and R1 engaged in additional behaviors such as wandering into other residents' rooms. On 07/24/2026, R1 was placed on 1:1 care due to the wandering behavior. An incident occurred on 08/01/2026 with R1's private companion present where R1 took an item from another resident, the other resident grabbed R1 by the arm and in response R1 grabbed that resident's hand. Neither resident sustained injury as a result of the interaction. To ensure resident safety, R1 continued to have a 1:1 companion until 08/14/2026. The incident referred to in the complaint occurred on 08/24/2026. Interview revealed that at approximately 02:45PM, R1 was seen in the hallway outside R2's room. Staff #1 (S1) redirected R1 away from R2's room. S1 watched R1 turn and head the other direction, so S1 left the area to obtain supplies to assist R2. Less than a minute later, when S1 returned to R2's room, they could hear R2 yelling for help. S1 entered the room and observed R1 laying on top of R2 in R2's bed, holding R2's face against the wall. When S1 attempted to remove R1 from R2's room, R1 scratched S1. S1 called for additional staff to assist. Multiple staff responded and noted R2 had small cuts on their face and marks on their neck. Both residents were taken to the emergency room for additional treatment following the incident. Staff interviewed indicated they were aware of R1's behavioral expressions, however, none interviewed had seen R1 have this level of aggressive behaviors prior to this incident. Immediately following the incident and ongoing, R1 has had a 1:1 private companion present. R1 was issued a 30-day eviction notice on 08/31/2026. Management indicated at this time, R1 does need the 1:1 companion for safety until R1 moves out or R1's medications are adjusted to better suit R1's needs. Although a physical altercation did occur between R1 and R2, there was no documentation of physical aggression prior to this incident and no staff had observed R1 engaging in this type of behavior. R1 did not require 1:1 supervision at the time of the incident and staff responded quickly when the incident occurred. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.
No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided.
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