Incident investigation·March 12, 2025

Licensing Program Analyst (LPA), Hannah Rodgers conducted a Case Management - Incident visit. LPA identified themselves and met with Executive Director Jennifer Ortega, to discuss the purpose of the visit. The facility self reported an incident that occurred on February 18, 2025 involving Resident #1(R1), Resident #2(R2), Resident #3(R3), Resident #4(R4) and Staff #1(S1) [ See LIC811 Confidential Name List for identification of select person identifiers used in this report]. The incident report indicated S1 was rough with R1, R2, R3, and R4 while providing care. S1 was placed on suspension and their last day worked was February 18, 2025. S1 officially resigned from the facility February 25, 2025. LPA conducted interviews with residents and staff. Staff interviews provided conflicting information. Per interviews, S1 was designated to the memory care floor primarily on the right wing. Per staff interviews, the right wing is challenging as there are eight residents who require total assistance with transfers from and to wheelchairs, including R1, R2, R3, and R4. LPA attempted to interview R1, R2, R3, R4, and a sample of their floor mates, but due to their baseline memory loss, each was unable to be qualified as a reliable historian for this case. Interview with S1 did not reveal they had been rough with residents and denied the allegations. Based on interviews and records review, there did not yield a preponderance of evidence to conclude that S1 was rough with residents. No deficiencies were cited during the visit. An exit interview was conducted with Executive Director Ortega, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.