Lake Stockton Healthcare Facility

During an interview on 01/01/26, at 1:01 P.M., CNA D said the following:-If he/she witnessed a resident-to-resident altercation, he/she separated the residents and reported to the charge nurse immediately;-The DON or Administrator reported to DHSS within 24 hours;-If Resident #1 and Resident #2 had an altercation, the DON or Administrator should have reported to DHSS.

During an interview on 01/01/26, at 1:13 P.M., Licensed Practical Nurse (LPN) E said the following: -If he/she witnessed a resident-to-resident altercation, he/she separated the residents and reported to the DON immediately. He/she also sent the residents out for psychiatric consult, notified the resident physician and responsible party, assessed the residents for injuries, and completed an incident and ROC report;-The altercation was reported by the DON or Administrator to DHSS, but he/she did not know how long they had to report;-If Resident #1 and #2 had an altercation, the DON or Administrator should have reported the incident to DHSS.

During an interview on 01/01/26, at 2:25 P.M., Registered Nurse (RN) F said the following:-If a CNA or CMT witnessed a resident-to-resident altercation, they should separate the residents and report to the charge nurse immediately;-The charge nurse assessed the residents and reported to the DON immediately;-The DON or Administrator reported to DHSS within two hours;-The DON or Administrator should have reported the altercation between Resident #1 and #2 to DHSS.

During an interview on 01/01/26, at 2:43 P.M., the DON said the following:-If staff witnessed a resident-to-resident altercation, the CNA or CMT reported to the charge nurse immediately and the charge nurse reported to the DON or Administrator immediately after the residents were assessed;-The Administrator reported to DHSS within two hours;-The charge nurse notified the physician and residents responsible parties and placed the residents on increased monitoring if needed;-All allegations of abuse were reported to DHSS within two hours;-On 10/17/25, he/she received a call from the charge nurse that Resident #1 threw a spoon at Resident #2 and then Resident #1 went over to Resident #2 and the nurse was not sure if Resident #1 shoved Resident #2 or if Resident #1 tripped and fell on Resident #2.

The nurse reported that both residents fell with Resident #2 still in the chair;-Staff separated the residents and the nurse assessed and neither had any injuries;-He/she asked the nurse to make an incident report;-The incident between the residents should have been reported to DHSS. He/she did not report to DHSS and did not know if anyone else did;-He/she was responsible for ensuring staff know when to report abuse.During an interview on 01/01/26, at 1:46 P.M. and 3:04 P.M., the Administrator said the following:-If staff witnessed a resident-to-resident altercation, the CNA or CMT separated the residents and reported to the charge nurse immediately.

The charge nurse assessed the residents and reported to the on-call RN immediately and notified the residents' responsible parties and physicians.

The on-call RN reported to the DON and Administrator immediately;-He reported to DHSS within two hours;-All allegations of abuse were reported to DHSS;-He called the DON and agreed to keep the residents separated;-He did not report the incident to DHSS because he thought if two confused residents were involved and there was no harm, he did not have to report to DHSS;-He should have been reported the incident to DHSS;-He was ultimately responsible for ensuring all staff know what to report and when to report it.#2705258

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