Incident investigation·March 20, 2025

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, March 20, 2025, and met with the Senior Executive Director, Janelle Odishoo, to follow-up on an SOC341 received by the department on March 12, 2025. LPA also received the facility's internal investigation findings on March 14, 2025. According to the SOC341, on March 11, 2025, the Senior Executive Director received a report from staff (S5) alleging that abuse had been reported to them from staff (S2) regarding resident (R1). S2 alleged that, during the AM shift, they witnessed staff (S1) forcefully grab R1's arms when assisting them onto the toilet on March 6, 2025. S1 had not reported the allegation to their supervisor at the time of the event. S1 was placed on leave pending an internal investigation. According to interview with the Senior Executive Director and documentation obtained, staff (S4) and staff (S6) conducted a head to toe skin check of R1 as well as all other residents residing in Reminiscence Care. All residents in Reminiscence Care have advanced stages of Dementia. S4 and S6 observed that R1 had a small bruise on their hand from a TB blood draw conducted that morning as well as some slight redness on their upper arm from the tourniquet. There were no other residents with any unusual or unexplained bruising, skin tears, or discoloration of skin. S4 and S5 interviewed S1 and S2 who provided written statements that had discrepancies regarding the incident. S4 and S5 interviewed all staff in Reminiscence Care and no interviews corroborated with S2's statement. According to interviews with staff that routinely provide care for R1, staff provide incontinence care at bedside as opposed to in the restroom, due to R1's behavioral expressions. S4 notified R1's family and physician. S4 conducted an in-service training for all three shifts regarding abuse reporting requirements, internal event reporting requirements, techniques used for ADL care and transferring for residents with dementia and behavioral expressions. LPA obtained a copy of the in-service training documentation. The facility's internal investigation was completed on 3/12/25 with Unsubstantiated findings. S1 will be re-instated to their position and returning to work March 23, 2025. LPA toured facility observing residents receiving care and participating in today's event. No concerns were observed. During today's visit, no citations are being issued. Exit interview conducted and copy of report provided.