Incident investigation·August 2, 2024

Licensing Program Analysts (LPAs) Brian Balisi and Trevor Byrne conducted an unannounced Case Management – Incident visit at 9:30 a.m. for the purpose of investigating self-reported incident reports. Upon arrival, LPAs met with Program Director Christian Havsgaard and explained the reason for the visit. On 08/01/2024, the Department reviewed an incident report stating on 07/12/2024, Staff #1 (S1) was inside resident 1’s (R1) room. R1 is not bedridden but is unable to leave their bed without assistance. R1 stated that they required a cleaning that day, R1 requires a two (2) person assist with cleaning. S1 was alone at the time of the request but told R1 that they could perform the cleaning by themselves. R1 refused stating that it was unsafe for both of them, and two (2) people are required. S1 continually insisted that they could perform the cleaning solo but R1 continually refused. R1 stated that S1 was verbally abusive during the exchange. On 07/22/2024 after changing the sheets on R1s bed R1 asked S1 and Staff #2 (S2) to shift her bed. S1 and S2 began trying to shift the bed without unlocking the wheels. R1 informed the staff members that they had to unlock the wheels at which point S1 began being verbally aggressive towards the resident. S1 raised their fists at R1 and asked if the resident wanted to fight them. R1 confirmed that S1 has been verbally abusive on multiple occasions. On 07/06/2024 S2 and staff #3 (S3) were assisting resident #2 (R2) in the restroom. R2 leaned to the side and at this point S2 struck R2 in the head to straighten their body. S3 told S2 that this is elder abuse and they needed to stop. S2 stated that it is only elder abuse if it is reported. The department received the SOC341 for this incident on 08/02/2024. At approx. 09:35 a.m., LPAs conducted physical plant, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation. LPAs have determined further investigation is needed and will return at a later date to continue. Exit interview conducted. A copy of the report was issued.