Incident investigation·July 31, 2025

On July 31, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on July 8, 2025. LPA met with Director of Health Services (DHS), Amyda Astrero and explained the purpose of the visit. The Licensee reported, on 7/8/25, a med-tech reported to the DHS that Staff 1 (S1) reported on 7/6/25, Resident 1 (R1) refused to go out of his/her room because he/she was afraid of Staff 2 (S2). The med-tech spoke to R1 and R1 indicated that S2 is rough to R1 and pushed R1 against the wall. DHS conducted an investigation and asked R1 is he/she knew the staff and R1 stated S2's name and stated S2 threw him/her against the wall and left him/her in a bad position. No injuries were notes. S2 was suspended pending investigation. During the investigation, LPA reviewed R1's file, reviewed facility's investigation and attempted to interview S2 and R1. R1 was not interviewable during the visit as he/she was eating lunch. S2 was not working during the time of the visit. Based on R1's file reviewed, R1 has a diagnosis of dementia, however does not have any aggressive or violent behaviors. According to the DHS, this is the first time R1 accused a staff of being aggressive towards him/her. Based on the facility's investigation, the findings went unsubstantiated as no staff member from the PM shift on 7/6/25 witnessed the incident. DHS provided training documents for S2 and will complete an in-service training with all staff on 7/31/25. According to the DHS, S2 is back to work, however is in a different neighborhood from R1. No citations are issued during the visit. Report is reviewed with Director of Health Services and a copy is provided.