Incident investigation·May 4, 2022

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Lupe Villa-Guerrero, Director of Health Services. LPA is following up regarding a self reported Incident Report and SOC 341 received on April 26,2022 regarding an incident that occurred on April 14, 2022. S1 witnessed R1 being walked down the hall by S3. S3 had there arms under R1's arms and was making R1 walk at a fast pace. R1 began to scream for help. S2 spoke to S3 and explained they should not be rushing R1. S2 immediately evaluated R1 and no injuries were found. R1 has dementia, shortly questioned afterward by S2 did not recall the incident. Facility did report incident to Ombudsman and per Director of Health Services Local Police conducted an investigation. Per agency staff S3 has not returned to agency and refused any interviews. Per Dir. of Health S3 is not allowed back at facility. LPA confirmed S3 has cleared finger prints in the system but is not and never was associated to this facility or the agency S3 was working through. No deficiencies cited during this inspection.