Incident investigation·August 20, 2024

Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced case-management incident visit in regards to a Special Incident Report (LIC624) that was submitted to Regional Office (RO) on 08/01/24 by facility. LPA Reyes met with Administrator Liyon O’ Quinn and explained the reason for the visit. Per Special Incident Report on 7/27/24, Resident #1 (R1) reported to staff #1 (S1) that during dinner time R2 was crying, shaking, and stated was afraid of S2. S2 stated while R2 was in the elevator being transported to the dinning area R2 was agitated and tried standing up from wheelchair. S2 stated while in the elevator R2 stood up from the wheelchair, S2 pulled R2 back in the chair, then R2 was yelling and crying in dinning room. During the Case-Management review of records and interviews were conducted on 08/20/24. LPA Reyes obtained and reviewed documents related to S2’s training, nursing safety standards, and job responsibilities. LPA Reyes conducted interviews with S2-S4 and R1-R4. Administrator Liyon stated S2 is not employed with facility. Administrator Liyon provide S2’s last day of employment and letter resigning from the facility.LPA Reyes toured the facility and no health and safety concerns were observed during the visit. Based on interviews, a ciation is being issued. See LIC 809D. An exit interview was conducted. A copy of LIC 809, LIC 809D, & Appeal Rights were provided to Administrator Liyon.