Incident investigation·January 31, 2025

On January 31, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident report the Department received. LPA met with med-tech and explained the purpose of the visit. Additionally, LPA spoke with Administrator on the phone to inform Administrator of LPA's purpose. Incident report revealed that on January 23, 2025, S1 observed S2 asking R1 who is the current president, how many pills did R1 take. When R1 responded "I don't know", it was observed that S2 responded "you don't know anything, you have dementia." LPA and Administrator discussed the following incident. Administrator stated when it was reported to the Administrative Office, S2 has then been removed from the schedule and no longer works at the facility. Administrator stated the incident was self reported and corrective actions were taken immediately. As a result of the reported behavior of S2, deficiencies was cited. LPA explained that although facility took appropriate actions, since the incident did occurred at the facility, it was a violation against personal rights. Exit interview and a copy of report and appeal rights provided.