Incident investigation·March 5, 2025

On 03/05/25 around 10:00 AM L. Holmes, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding two (2) Unusual Incident Reports (UIRs). LPA was greeted by the Receptionist and explained the purpose of the visit while Jeffrey Emoruwa, Administrator (ADM) attended a meeting. ADM arrived about ten (10) minutes later. On 02/21/25, LPA received an email from ADM reporting 2 staff made physical contact with 2 residents on 2 different occasions. The facility became aware of the incidents evening on 02/19/25, and the investigation is still in progress. Staff (S1, S2) were suspended on 02/19/25 pending the results of the investigation; residents involved were (R1, R2). S4 alleged that S1 made contact to R1's left cheek while trying to stop R1 from be being agitated, throwing glass and trying to hit at S1. S4 stated that the incident happened in the dining area about a month ago (01/2025) S3 alleged that S2 slapped R2's forearm in an effort to prevent R2 from placing his/her hands inside their own briefs. S3 stated that the incident occurred about 2 months ago (12/2024) in R2's bedroom. Human Resources conducted a one (1) day investigation on site, and 1 day of calling for interviews; four (4) additional caregivers and 2 nurses were assigned to the facility to assist. W1 interviewed ADM also. S1 resigned prior to completion of the investigation. At this time, the facility's investigation is inconclusive. Exit interview conducted and a copy of this report provided to Jeffrey Emoruwa, Administrator.