Incident investigation·July 1, 2025

On 07/01/2025 at 12:40 PM Licensing Program Analyst (LPA) P. Manalo conducted an unannounced Case Management visit regarding a self-reported restraint abuse that occurred on 06/23/2025. Health Services Director, Leslie Ibo self-reported the incident on 06/23/2025. LPA met with General Manager, Ryan Turner, and explained the purpose of the visit. LPA reviewed the following documents such facility’s Resident Incident Report, Physician’s Fax Report, Progress Notes, and SOC341. LPA also reviewed the AUGi monitoring system during today's visit. LPA interviewed Staff 1 (S1) and Staff (2). Interview with S1 revealed that S1 heard motion in R1’s room and checked the AUGi Monitoring System. AUGi system showed that R1 was laying down and the 1:1 caregiver was holding R1 down on the bed. S1 and another staff member proceeded to intervene. Interview with S2 and Progress Notes for R1 showed that the R1 did not sustain injuries during the assessment. General Manager stated that the private caregiver was sent home and will not be allowed at the facility anymore. LPA will have the facility send the 1:1 Private Caregiver Contract by 04/07/2025. No deficiencies cited during visit. Exit interview was conducted with General Manager and a copy of this report was provided.