Incident investigation·May 21, 2025

05/21/2024 10:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Stacey Baxter. Today’s visit is regarding an incident that occurred on 05/13/2025. It was reported that on 05/14/2025 Staff 2 (S2) reported to Staff 3 (S3) and Staff 4 (S4) on 05/12/2025 that Staff 1 (S1) was verbally abusive toward Resident 1 (R1) and Resident 2 (R2). S1 was cursing and yelling at the two residents because they were not doing what she wanted them to do. In S2’s statement she stated that S1 had gotten R1 out of bed and wheeled R1 into the hallway, shoved their wheelchair, and told R1 to take themself to the dining room. Executive Director Stacey Baxter reviewed surveillance camera footage and confirmed that S1 shoved R1’s wheelchair into the hallway which caused R1 to roll almost into the wall. At this point another resident came out of their room and pushed R1 to the dining room. S1 came out of the room and walked right past both residents without acknowledging them. An internal investigation was conducted and the employee was terminated as a result. Continued on LIC809-D LPA reviewed the video surveillance of the incident and observed the following: Staff 1 was seen aggressively shoving R1’s wheelchair out of their room and down the hall, R1 nearly hit the wall and was left there alone. Surveillance footage shows S1 come out of the room swinging R1’s soiled brief in the air as they walked down the hall. The surveillance footage shows S1 ignoring R1 as they walked down the hall. It was determined that Staff 1 (S1) handled R1 in a rough manner when they pushed their wheelchair into the hall, left R1 alone and ignored R1 ED terminated S1 as a resuly of this incident. Since ED self reported this incident in detail, shared video footage with LPA and terminated the involved staff a technical violation is being issued as a result of this investigation. No deficiencies were cited as a result.