Incident investigation·October 29, 2024

Licensing Program Analyst (LPA) Tao conducted an unannounced Case Management- Incident visit in response to resident#1 (R1) Incident Report, dated 10/05/24. The facility has a capacity of 142 residents, licensed to serve elderly residents age 60 and above, approved for 142 non-ambulatory residents and has dementia program in place. LPA explained the purpose of today's visit to LeeAnn Hefner, administrator who assisted with this visit. During today's visit, LPA conducted physical plant, conducted interviews including Administrator, staff#2-staff#3, resident#1 (R1) and family member (FM), reviewed R1's file and staff file. LPA attempted but unable to reach staff#4 (S4) and the agency caregiver (S5) for interview. The incident report stated an agency caregiver (S5) reported to administrator that staff#4 (S4) was rough with resident#1 (R1) while providing care. The agency caregiver reported S4 did not use the Hoyer Lift to transfer resident, grabbed resident by resident’ neck and did not provide proper pericare to resident. LPA interviewed Administrator/staff revealed that the facility investigated the incident, put the alleged staff (S4) on an immediate suspension on 10/04/24, and reported the incident to Licensing/ ombudsman / responsible party/ police on 10/05/24. The staff interviews revealed it was a single incident and resident#1 (R1) was not injured nor physically abused. Staff S4 was a new hired and had completed training on providing care to dementia residents. S4 was voluntarily terminated on 10/07/24 after the incident. After the incident, the administrator hosted a brief meeting with caregivers regarding the proper procedures on providing cares to residents with dementia and using Hoyer Lift. Per interview of R1, resident seemed unable to recall the incident and did not observe injury on resident’s neck or back. R1 was on a daily monitor by staff for a week. FM interview revealed R1 was doing fine and did not complain any pain after the incident. Police case#24-22261. (-continued on LIC 809C-) LPA obtained copies of the following documents: · Staff roster · Resident roster · R1’s Identification/Emergency Contact Information (facesheet) · Unusual Incident Report · Physician Report · Staff #4 staff files/document · In-service training LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. No deficiencies were observed and cited during this visit. Exit interview was held with administrator and this report LIC 809 was provided to administrator.