Complaint Investigation Report

On 02/04/25 an incident report was received by Community Care Licensing (CCL) stating that on 1/31/25 two (2) clients were involved in an argument, Client #1 (C1) hit Client #2 (C2) in the face with a cane, and C2 hit C1 in the face with a lunch pail. Both staff on duty were within less than 10 feet from the residents. Staff placed themselves in-between the clients, addressed and ended the altercation. Following the altercation, per interviews, observation of the living room by LPA, and incident reports submitted, staff moved furniture to facilitate safe space between clients. Incident was reported on 2/3/25 to Program Director. Mandated Reporting training was conducted to reinforce time frames for reporting incidents.

On 2/1/25, C2 yelled that C3 hit them on their arm. C2 tried to scratch C3. Staff tried to encourage clients to separate and attempted to redirect clients. Clients refused. Clients C2 began yelling and C3 grabbed C2. Staff immediately responded and got between clients and directed C2 to go to their room. Staff #1 (S1) checked C2 for marks and found no marks on C2 at the time of the incident. LPA noted that C2 has a severe hunch or forward slump to their stance, and C2 is shorter in stature and during interview and previous interviews the view of the LPA for C2 was the top of their head. This is necessary to note, as S1 stated it wasn’t until they were on their way to the hospital with C2 that they noted a discoloring around C2’s eye. S1 does not believe the discoloring was there at the start of their shift on 2/1/25.

Following incidents C2 was taken to the Emergency Room due to agitation and pre-existing heart condition. Notes from hospital visit were obtained by LPA on 2/20/25. Notes indicate "ecchymosis" (discoloration) above the right eye. No other injuries found.

LPA interviewed C2 and asked about both incidents. C2 remembers being hit by a cane and confirmed that C3 grabbed C2. Interview with S1 confirmed events above with differing of they do not believe that contact was made with the first incident, but due to client and staff interviews done by management and LPA, it is believed that contact with the cane and lunch pail were made. Interview with S2, stated they were in the med area which has a direct line of site to the living room and S2 viewed the incident where C1 swung their cane and made contact with C2’s face.

LPA interviewed Deputy who responded to the incident, due to a call from the hospital. Deputy stated no crime was committed, no visible injuries were noted and interviews with caregiver stated that staff attempted to prevent and de-escalate the altercation.