Incident investigation·June 12, 2024

On 6/12/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit, met with Jessica Sanders and explained the reason for the visit. On 6/6/24, the department received a SOC 341 submitted by the Director, Jessica Sanders. The report stated that on 6/4/24, medication tech S1 forced R1 to take medications at approximately 8 PM, after R1 had spit out R1's medications at the medication tech. S1 was assisted by caregivers S2 and S3 who restrained R1 while S1 put medications in R1's mouth and S1 covered R1's mouth so that R1 could not spit the medications out again. It is not known if resident spit out all medication in their entirety before additional medications were forced. S4 reported the incident to the Memory Care Director on 6/5/24. S5 reported the incident to the Director on 6/6/24. During this visit LPA interviewed the Director. Director stated S1's employment has been terminated. S2 and S3 are currently suspended pending further action. Staff training has been reviewed for staff present that shift regarded mandated reporting, resident right to refuse meds and no restraint policy with S1-S5.. Additional staff training to be done for all staff as part of the plan of correction (POC) LPA received copies of S1, S2 and S3 employee records, R1's physician's report and medication administrative record, staff schedules for 6/4/24, as well as staff statements, by S1-S5, collected in the course of the facility's investigation. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided