Incident investigation·July 13, 2023

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on two incident reports. LPA Moleski met with administrator Morgan Whinery and explained the purpose of the visit. LPA Moleski reviewed an incident report that described a resident (R1) tipping over in their wheelchair while on their way back to the facility in a van. The driver did not fasten R1's seat belt, according to the incident report. The driver pulled over afterward and paramedics were called. R1 refused transport to the hospital. Paramedics helped R1 back into a sitting position. Bruises were later found on R1's knees, and R1 said they hit their head, according to the report. LPA Moleski interviewed administrator Morgan Whinery. R1 is able to leave the facility unassisted. The van was publicly operated, according to Whinery. LPA Moleski also reviewed an incident report that described a resident (R2) walking out of a cottage and down into the street. According to Morgan, staff followed along with her until paramedics arrived. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Whinery.