Incident investigation·August 22, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit regarding incident report submitted to the department on 8/6/24 and 8/8/24. LPA met with Stephanie Funderburg and explained the reason for the visit. On 8/6/24 an incident report was submitted to the department regarding a notification of physically abused by a staff towards two residents in the memory care unit. On 8/1/24, two staff stated to have witness, staff #1(S1) hitting resident #1(R1) firmly in the hand on 7/26/24 and using force to provide assistance to resident #2(R2) on 7/29/24. Interviews conducted and documents reviewed by LPA revealed staff had observed S1 slapped/snatched R1's hand as R1 requested for assistance as S1 walked by. As well as on 7/29/24, S1 had provided assistance to R2 by bending down the leg and using force to lift it up resulting on R2 screaming. LPA was unable to interview residents due to cognitive skills. No injuries were caused to the residents due to staff's behavior. Facility reported it to all pertaining agencies and conducted an internal investigation and substantiated the allegation against S1. S1 was notified of a suspension and investigation verbally and via email on 8/2/24. On 8/6/24 a Notice of Employee Separation and staff was terminated from the facility after suspension of suspected abuse. Police department conducted a visit and left report #PA24-61517. Due to physical abuse observed by staff towards two residents, Deficiency is noted on LIC 809D regarding this incident. On 8/8/24 an incident report was submitted to the department regarding resident #3(R3) provided Heimlich maneuver assistance after staff noticed R3 was chocking during breakfast in the memory care unit dining room on 8/4/24. LPA interviewed the staff who witness and assisted during the incident. Per staff R3 was on a finely chopped diet and was having breakfast at around 10:00am. Dining server noticed R3 was not breathing and went to call Med-tech for assistance. (CONTINUED ON LIC 809C) Med-tech checked on R3 and asked dining server to stay with R3 while staff called 911. Kitchen director went to provided assistance with the incident and attempted to clear the airway by removing food observed in R3's mouth and perform Heimlich maneuver. Med-Tech returned and took over. First responders arrived within 3-4 minutes and took over assisting R3. R3 was transferred to the hospital. LPA reviewed R3's file, per physician's report dated 7/15/24, R3 was on a finely chopped diet. LPA observed observed kitchen staff prepare a finely chopped diet, which consist of dicing all food items served to the residents. After interviews and documents reviewed facility staff provided assistance to R3 as soon as the incident was observed. No deficiencies noted regarding incident occurred on 8/4/24. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.