Incident investigation·October 4, 2024

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA met with Executive Director, Reginald Jones to discuss the purpose of the visit.. Today's visit was in response to a timely self reported incident that occurred on 08/24/24 involving Resident #1 (R1) and Staff #1 (S1). The incident report stated S1 hit R1 four (4) days prior on 08/21/24 for refusing medication. The facility assessed R1 and there were no injuries. The Executive Director met with R1, R1's responsible party to discuss the incident and unpaid rent. After the incident was reported, the facility implemented a two (2) persons assist required for all care and medication pass to ensure witnesses present for all care for R1. S1 denied the allegation and stated R1 refuses medication regularly but there has never been an issue of abuse. R1's Medication Administration Record confirmed R1 regularly refuses medications. It was also reported the incident occurred 08/21/24 and/or 08/23/24, conflicting statements were made about the date of the incident. Resident interview indicated not being aware of the incident and never witnessing S1 hit R1. The facility observed R1 having increased confusion and scheduled an appointment for R1 with R1's physician and a psychologist. R1 moved out of the facility on 09/14/24 with an outstanding balance. No deficiencies were observed or cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Staff #1]