Incident investigation·May 27, 2025

On May 27, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management in relation to an incident that occurred on 4/27/25. LPA met with Administrator, Robert Snee and explained the purpose of the visit. On 4/27/25, the Licensee reported, the facility's engagement assistant (S1) observed Resident 1's (R1's) 1:1 caregiver sitting outside the door holding the door knob preventing R1 from leaving the room. All required parties were notified. New medications were ordered and 1:1 caregiver was terminated. During the visit today, LPA interviewed staff and reviewed R1's file. Based on file reviewed, R1 has a diagnosis of advanced dementia and a previous history of aggressive behavior, however was on medication to stabilize his/her aggressive behaviors. R1's behavior stabilized so the physician stopped the medication, however R1 started having aggressive behaviors. According to staff interviewed, the 1:1 caregiver was through a third party vendor/agency the facility uses, however the family contracted with the vendor/agency directly. The Director of Health Services indicated, when S1 witnessed 1:1 caregiver sitting outside holding R1's door knob preventing R1 from leaving his/her room, S1 immediately let R1 out of the room and walked him/her around outside. 1:1 caregiver is no longer allowed to come back to the facility and another 1:1 caregiver was hired to assist R1. R1 has a weekly psychiatrist appointments and medication management has been implemented. No citations are issued during the visit. Report is reviewed with the administrator and a copy is provided.